Basic Information
| Provider Information | |||||||||
| NPI: | 1033150610 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | PHILLIPS | ||||||||
| FirstName: | SAMUEL | ||||||||
| MiddleName: | P | ||||||||
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| Credential: | M.D. | ||||||||
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| Mailing Information | |||||||||
| Address1: | 17030 LAKESIDE HILLS PLZ | ||||||||
| Address2: | SUITE 200 | ||||||||
| City: | OMAHA | ||||||||
| State: | NE | ||||||||
| PostalCode: | 681302396 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4023998550 | ||||||||
| FaxNumber: | 4023998455 | ||||||||
| Practice Location | |||||||||
| Address1: | 7710 MERCY RD | ||||||||
| Address2: | SUITE 224 | ||||||||
| City: | OMAHA | ||||||||
| State: | NE | ||||||||
| PostalCode: | 681242372 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4023998550 | ||||||||
| FaxNumber: | 4023998455 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 06/08/2006 | ||||||||
| LastUpdateDate: | 06/08/2011 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207X00000X | 19522 | NE | Y | Allopathic & Osteopathic Physicians | Orthopaedic Surgery |
ID Information
| ID | Type | State | Issuer | Description | 30680 | 01 | NE | BCBS NEBRASKA | OTHER | 1576975 | 05 | IA | MEDICAID | 47063010113 | 05 | NE | MEDICAID |