1467118075 NPI number — EDWARD J PHILLIPS CYC, CIT-HS-00158

Table of content: EDWARD J PHILLIPS CYC, CIT-HS-00158 (NPI 1467118075)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1467118075 NPI number — EDWARD J PHILLIPS CYC, CIT-HS-00158

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
PHILLIPS
Provider First Name:
EDWARD
Provider Middle Name:
J
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
CYC, CIT-HS-00158
Provider Gender Code:
M

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
PHILLIPS
Provider Other First Name:
EDWARD
Provider Other Middle Name:
J
Provider Other Name Prefix Text:
MR.
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:
2

NPI Number Information

NPI Number:
1467118075
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
07/20/2022
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
PO BOX 251970
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
LITTLE ROCK
Provider Business Mailing Address State Name:
AR
Provider Business Mailing Address Postal Code:
72225
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
501-666-8686
Provider Business Mailing Address Fax Number:
501-660-6830

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
1521 MERRILL DRIVE
Provider Second Line Business Practice Location Address:
STE D220
Provider Business Practice Location Address City Name:
LITTLE ROCK
Provider Business Practice Location Address State Name:
AR
Provider Business Practice Location Address Postal Code:
72211
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
501-666-8686
Provider Business Practice Location Address Fax Number:
501-660-6830
Provider Enumeration Date:
11/09/2021

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: 101YA0400X , with the licence number:  CIT-HS-00158 , registered in the state of AR ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 171M00000X , registered in the state of AR ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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





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