1255366175 NPI number — MR. THIRSTON S PHILLIPS JR. DO

Table of content: MR. THIRSTON S PHILLIPS JR. DO (NPI 1255366175)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1255366175 NPI number — MR. THIRSTON S PHILLIPS JR. DO

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
PHILLIPS
Provider First Name:
THIRSTON
Provider Middle Name:
S
Provider Name Prefix Text:
MR.
Provider Name Suffix Text:
JR.
Provider Credential Text:
DO
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:
1255366175
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
10/27/2021
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
PO BOX 31166
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
MYRTLE BEACH
Provider Business Mailing Address State Name:
SC
Provider Business Mailing Address Postal Code:
29588-0020
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
910-495-6287
Provider Business Mailing Address Fax Number:
910-222-3063

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
100 WATER GRANDE BLVD
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
LITTLE RIVER
Provider Business Practice Location Address State Name:
SC
Provider Business Practice Location Address Postal Code:
29566-8162
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
843-366-4000
Provider Business Practice Location Address Fax Number:
910-222-3063
Provider Enumeration Date:
07/11/2006

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: 208100000X , with the licence number:  200400575 , registered in the state of NC ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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

  • Identifier: 136YW . This is a "BLUE CROSS AND BLUE SHIEL" identifier , issued by the state of ( NC ) . This identifiers is of the category "OTHER".
  • Identifier: 195400 . This is a "MEDCOST PROVIDER ID" identifier , issued by the state of ( NC ) . This identifiers is of the category "OTHER".
  • Identifier: Q0057F , issued by the state of ( SC ) . This identifiers is of the category "MEDICAID".
  • Identifier: 89136YW , issued by the state of ( NC ) . This identifiers is of the category "MEDICAID".
  • Identifier: 612107500 . This is a "OWCP PROVIDER ID" identifier , issued by the state of ( NC ) . This identifiers is of the category "OTHER".




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