1912904905 NPI number — DR. BRUCE W. PHILLIPS M.D.

Table of content: DR. BRUCE W. PHILLIPS M.D. (NPI 1912904905)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1912904905 NPI number — DR. BRUCE W. PHILLIPS M.D.

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
PHILLIPS
Provider First Name:
BRUCE
Provider Middle Name:
W.
Provider Name Prefix Text:
DR.
Provider Name Suffix Text:
Provider Credential Text:
M.D.
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:
1912904905
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
04/19/2016
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
9960 CENTRAL PARK BLVD N
Provider Second Line Business Mailing Address:
SUITE 100
Provider Business Mailing Address City Name:
BOCA RATON
Provider Business Mailing Address State Name:
FL
Provider Business Mailing Address Postal Code:
33428-1759
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
561-226-4180
Provider Business Mailing Address Fax Number:
561-226-4199

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
9960 CENTRAL PARK BLVD N
Provider Second Line Business Practice Location Address:
SUITE 100
Provider Business Practice Location Address City Name:
BOCA RATON
Provider Business Practice Location Address State Name:
FL
Provider Business Practice Location Address Postal Code:
33428-1759
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
561-226-4180
Provider Business Practice Location Address Fax Number:
561-226-4199
Provider Enumeration Date:
07/05/2005

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: 2085R0001X , with the licence number:  ME 50838 , registered in the state of FL ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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

  • Identifier: 03999 . This is a "BCBS OF FL" identifier , issued by the state of ( FL ) . This identifiers is of the category "OTHER".
  • Identifier: 052EV1 . This is a "EMPIRE BCBS" identifier , issued by the state of ( NY ) . This identifiers is of the category "OTHER".
  • Identifier: 1029466 . This is a "WELLCARE" identifier , issued by the state of ( FL ) . This identifiers is of the category "OTHER".
  • Identifier: P0003198 . This is a "FLORIDA HEALTHCARE PLUS" identifier , issued by the state of ( FL ) . This identifiers is of the category "OTHER".
  • Identifier: P510999 . This is a "OPTIMUM" identifier , issued by the state of ( FL ) . This identifiers is of the category "OTHER".
  • Identifier: 046524100 , issued by the state of ( FL ) . This identifiers is of the category "MEDICAID".
  • Identifier: 052EV2 . This is a "EMPIRE BCBS" identifier , issued by the state of ( NY ) . This identifiers is of the category "OTHER".
  • Identifier: P01318677 . This is a "RR MEDICARE" identifier , issued by the state of ( FL ) . This identifiers is of the category "OTHER".
  • Identifier: 204369 . This is a "AVMED" identifier , issued by the state of ( FL ) . This identifiers is of the category "OTHER".
  • Identifier: 0544936 . This is a "CIGNA" identifier , issued by the state of ( FL ) . This identifiers is of the category "OTHER".
  • Identifier: 5402697 . This is a "AETNA" identifier , issued by the state of ( FL ) . This identifiers is of the category "OTHER".
  • Identifier: P01269 . This is a "FREEDOM HEALTH" identifier , issued by the state of ( FL ) . This identifiers is of the category "OTHER".
  • Identifier: 05717 . This is a "DIMENSION HEALTH" identifier , issued by the state of ( FL ) . This identifiers is of the category "OTHER".




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