Basic Information
| Provider Information | |||||||||
| NPI: | 1376852657 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | PHILLIPS,SALOMON & PARRISH, PA | ||||||||
| LastName: | |||||||||
| FirstName: | |||||||||
| MiddleName: | |||||||||
| NamePrefix: | |||||||||
| NameSuffix: | |||||||||
| Credential: | |||||||||
| OtherOrganizationName: | |||||||||
| OtherOrganizationType: | |||||||||
| OtherLastName: | |||||||||
| OtherFirstName: | |||||||||
| OtherMiddleName: | |||||||||
| OtherNamePrefix: | |||||||||
| OtherNameSuffix: | |||||||||
| OtherCredential: | |||||||||
| OtherLastNameType: | |||||||||
| Mailing Information | |||||||||
| Address1: | 215 1ST ST N | ||||||||
| Address2: | SUITE 100 | ||||||||
| City: | WINTER HAVEN | ||||||||
| State: | FL | ||||||||
| PostalCode: | 338814537 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8632998908 | ||||||||
| FaxNumber: | 8635952838 | ||||||||
| Practice Location | |||||||||
| Address1: | 1040 CYPRESS PKWY | ||||||||
| Address2: | |||||||||
| City: | POINCIANA | ||||||||
| State: | FL | ||||||||
| PostalCode: | 347593328 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4079332088 | ||||||||
| FaxNumber: | 4079331968 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 10/04/2010 | ||||||||
| LastUpdateDate: | 04/09/2013 | ||||||||
| NPIDeactivationReasonCode: | |||||||||
| NPIDeactivationDate: | |||||||||
| NPIReactivationDate: | |||||||||
| ProviderGenderCode: | |||||||||
| AuthorizedOfficialLastName: | PHILLIPS | ||||||||
| AuthorizedOfficialFirstName: | STEPHEN | ||||||||
| AuthorizedOfficialMiddleName: | F | ||||||||
| AuthorizedOfficialTitleorPosition: | DIRECTOR | ||||||||
| AuthorizedOfficialTelephone: | 8632998908 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
| ParentOrganizationLBN: | |||||||||
| AuthorizedOfficialNamePrefix: | DR. | ||||||||
| AuthorizedOfficialNameSuffix: | |||||||||
| AuthorizedOfficialCredential: | OD | ||||||||
| NPICertificationDate: | |||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 152W00000X | OPC1963 | FL | Y | 193400000X SINGLE SPECIALTY GROUP | Eye and Vision Services Providers | Optometrist |
ID Information
| ID | Type | State | Issuer | Description | 078873202 | 05 | FL | MEDICAID | 24518 | 01 | FL | MEDICARE PTAN | OTHER | 078873203 | 05 | FL | MEDICAID | 24518A | 01 | FL | MEDICARE PTAN | OTHER | 24518B | 01 | FL | MEDICARE PTAN | OTHER | 078873201 | 05 | FL | MEDICAID | 078873204 | 05 | FL | MEDICAID | 078873206 | 05 | FL | MEDICAID | 078873200 | 05 | FL | MEDICAID | 078873205 | 05 | FL | MEDICAID |