MEDICARE: GREGORY PHILLIPS DPM

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	213EP1101X	Primary Podiatric Medicine Podiatrist	442	NC
2	213ES0103X	Foot & Ankle Surgery Podiatrist	442	NC

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	08099	OTHER	NC	BLUECROSS BLUESHIELD

General Provider Information

NPI Number	:	1770663635
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	GREGORY PHILLIPS DPM

Provider Business Mailing Address
First Line	:	337 S WHITE ST
Second Line	:
City	:	WAKE FOREST
State	:	NC
Zip	:	27587-2916
Country	:	US
Telephone Number	:	919-554-0711
Fax Number	:	919-554-1185

Provider Business Practice Location Address
First Line	:	337 S WHITE ST
Second Line	:
City	:	WAKE FOREST
State	:	NC
Zip	:	27587-2916
Country	:	US
Telephone Number	:	919-554-0711
Fax Number	:	919-554-1185

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

Provider Enumeration Date	:	10/16/2006
Last Update Date	:	04/24/2009

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