Basic Information
| Provider Information | |||||||||
| NPI: | 1134295793 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | PHILLIPS | ||||||||
| FirstName: | JIMMY | ||||||||
| MiddleName: | WEBSTER | ||||||||
| NamePrefix: | |||||||||
| NameSuffix: | JR. | ||||||||
| Credential: | PT ATC | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 105132 | ||||||||
| Address2: | |||||||||
| City: | ATLANTA | ||||||||
| State: | GA | ||||||||
| PostalCode: | 303485132 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6153292294 | ||||||||
| FaxNumber: | |||||||||
| Practice Location | |||||||||
| Address1: | 1800 MEDICAL CENTER PARKWAY | ||||||||
| Address2: | SUITE 200 | ||||||||
| City: | MURFREESBORO | ||||||||
| State: | TN | ||||||||
| PostalCode: | 37129 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6158966800 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 11/27/2006 | ||||||||
| LastUpdateDate: | 01/25/2010 | ||||||||
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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 | 225100000X | TN4906 | TN | Y | Respiratory, Developmental, Rehabilitative and Restorative Service Providers | Physical Therapist | 2255A2300X | TN389 | TN | N | Respiratory, Developmental, Rehabilitative and Restorative Service Providers | Specialist/Technologist | Athletic Trainer |
ID Information
| ID | Type | State | Issuer | Description | 3650135 | 05 | TN | MEDICAID |