1124062443 NPI number — DR. KELLEY L PHILLIPS KELLEY PHILLIPS MD

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1124062443 NPI number — DR. KELLEY L PHILLIPS KELLEY PHILLIPS MD

Employer Identification Number (EIN):

Provider Organization Name:

Provider Last Name:

PHILLIPS

Provider First Name:

KELLEY

Provider Middle Name:

L

Provider Name Prefix Text:

DR.

Provider Name Suffix Text:

Provider Credential Text:

KELLEY PHILLIPS MD

Provider Gender Code:

F

Provider Other Organization Name:

Provider Other Organization Name Type Code:

Provider Other Last Name:

Provider Other First Name:

Provider Other Middle Name:

Provider Other Name Prefix Text:

Provider Other Name Suffix Text:

Provider Other Credential Text:

Provider Other Last Name Type Code:

NPI Number:

1124062443

Entity Type Code:

Individual

Replacement NPI:

Last Update Date:

02/26/2019

NPI Deactivation Reason Code:

NPI Deactivation Date:

NPI Reactivation Date:

Provider First Line Business Mailing Address:

3322 DENT PL NW

Provider Second Line Business Mailing Address:

Provider Business Mailing Address City Name:

WASHINGTON

Provider Business Mailing Address State Name:

DC

Provider Business Mailing Address Postal Code:

20007-2712

Provider Business Mailing Address Country Code:

US

Provider Business Mailing Address Telephone Number:

202-337-8051

Provider Business Mailing Address Fax Number:

202-338-4436

Provider First Line Business Practice Location Address:

875 W MORENO AVE

Provider Second Line Business Practice Location Address:

Provider Business Practice Location Address City Name:

COLORADO SPRINGS

Provider Business Practice Location Address State Name:

CO

Provider Business Practice Location Address Postal Code:

80905-1731

Provider Business Practice Location Address Country Code:

US

Provider Business Practice Location Address Telephone Number:

719-572-6100

Provider Business Practice Location Address Fax Number:

Provider Enumeration Date:

06/16/2006

Authorized Official Last Name:

Authorized Official First Name:

Authorized Official Middle Name:

Authorized Official Title or Position:

Authorized Official Telephone Number:

• Taxonomy code: 2084P0800X , with the licence number:  MD13012 , registered in the state of DC ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
• Taxonomy code: 2084P0800X , with the licence number: DR.0061894 , registered in the state of CO ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

• Identifier: 185693 . This is a "BCBS VA" identifier , issued by the state of ( VA ) . This identifiers is of the category "OTHER".
• Identifier: P00479398 . This is a "RR MEDICARE ND" identifier , issued by the state of ( ND ) . This identifiers is of the category "OTHER".
• Identifier: 010206758 , issued by the state of ( VA ) . This identifiers is of the category "MEDICAID".
• Identifier: 0488015 , issued by the state of ( IA ) . This identifiers is of the category "MEDICAID".
• Identifier: P00384921 . This is a "RR MEDICARE X" identifier , issued by the state of ( DC ) . This identifiers is of the category "OTHER".
• Identifier: P00384921 . This is a "RR MEDICARE S" identifier , issued by the state of ( DE ) . This identifiers is of the category "OTHER".
• Identifier: 13831 , issued by the state of ( ND ) . This identifiers is of the category "MEDICAID".
• Identifier: 60484701 . This is a "BCBS MD" identifier , issued by the state of ( MD ) . This identifiers is of the category "OTHER".
• Identifier: 410407200 , issued by the state of ( MD ) . This identifiers is of the category "MEDICAID".
• Identifier: G396-0044 . This is a "BCBS DC" identifier , issued by the state of ( DC ) . This identifiers is of the category "OTHER".
• Identifier: P00356148 . This is a "RR MEDICARE IA" identifier , issued by the state of ( IA ) . This identifiers is of the category "OTHER".