MEDICARE: MS. MARY JOHNSON PHILLIPS

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	251B00000X	Case Management Agency	7631759	AL

General Provider Information

NPI Number	:	1699146266
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MS. MARY JOHNSON PHILLIPS

Provider Business Mailing Address
First Line	:	1117 WILLOUGHBY AVE
Second Line	:	APT. 3R
City	:	BROOKLYN
State	:	NY
Zip	:	11237-2745
Country	:	US
Telephone Number	:	917-929-3577
Fax Number	:

Provider Business Practice Location Address
First Line	:	1117 WILLOUGHBY AVE
Second Line	:	APT. 3R
City	:	BROOKLYN
State	:	NY
Zip	:	11237-2745
Country	:	US
Telephone Number	:	917-929-3755
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	10/08/2015
Last Update Date	:	10/08/2015

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