Basic Information
| Provider Information | |||||||||
| NPI: | 1013904721 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | PHILLIPS SALOMON & PARRISH PA | ||||||||
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| Mailing Information | |||||||||
| Address1: | 215 1ST ST N | ||||||||
| Address2: | SUITE 100 | ||||||||
| City: | WINTER HAVEN | ||||||||
| State: | FL | ||||||||
| PostalCode: | 338814537 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8632998908 | ||||||||
| FaxNumber: | 8632991061 | ||||||||
| Practice Location | |||||||||
| Address1: | 1251 LAKELAND HILLS BLVD | ||||||||
| Address2: | |||||||||
| City: | LAKELAND | ||||||||
| State: | FL | ||||||||
| PostalCode: | 338054673 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8636881545 | ||||||||
| FaxNumber: | 8635950927 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 09/29/2005 | ||||||||
| LastUpdateDate: | 02/08/2011 | ||||||||
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| AuthorizedOfficialLastName: | SALOMON | ||||||||
| AuthorizedOfficialFirstName: | BRAD | ||||||||
| AuthorizedOfficialMiddleName: | R | ||||||||
| AuthorizedOfficialTitleorPosition: | REGISTERED AGENT | ||||||||
| AuthorizedOfficialTelephone: | 8632998908 | ||||||||
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| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialNamePrefix: | DR. | ||||||||
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| AuthorizedOfficialCredential: | OD | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 152W00000X | Y | 193400000X SINGLE SPECIALTY GROUP | Eye and Vision Services Providers | Optometrist |
ID Information
| ID | Type | State | Issuer | Description | 078873204 | 05 | FL | MEDICAID |