1174627491 NPI number — DR. MARK DAVID PHILLIPS MD PHD

Table of content: DR. MARK DAVID PHILLIPS MD PHD (NPI 1174627491)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1174627491 NPI number — DR. MARK DAVID PHILLIPS MD PHD

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
PHILLIPS
Provider First Name:
MARK
Provider Middle Name:
DAVID
Provider Name Prefix Text:
DR.
Provider Name Suffix Text:
Provider Credential Text:
MD PHD
Provider Gender Code:
M

Provider's Other Name Information

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 Information

NPI Number:
1174627491
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
06/05/2018
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
9910 FRANKLIN SQUARE DR # 2110
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
BALTIMORE
Provider Business Mailing Address State Name:
MD
Provider Business Mailing Address Postal Code:
21236-4902
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
410-933-5412
Provider Business Mailing Address Fax Number:

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
4924 CAMPBELL BLVD STE 200
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
BALTIMORE
Provider Business Practice Location Address State Name:
MD
Provider Business Practice Location Address Postal Code:
21236
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
443-442-2300
Provider Business Practice Location Address Fax Number:
410-367-2035
Provider Enumeration Date:
09/08/2006

Additional Information

Authorized Official

Authorized Official Last Name:
Authorized Official First Name:
Authorized Official Middle Name:
Authorized Official Title or Position:
Authorized Official Telephone Number:

Provider Taxonomy Codes

  • Taxonomy code: 207Q00000X , with the licence number:  D55495 , registered in the state of MD ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)

  • Identifier: 699214500 , issued by the state of ( MD ) . This identifiers is of the category "MEDICAID".




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