Basic Information
| Provider Information | |||||||||
| NPI: | 1396702965 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | PHILLIPS | ||||||||
| FirstName: | DERRICK | ||||||||
| MiddleName: | D. | ||||||||
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| Credential: | M.D. | ||||||||
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| Mailing Information | |||||||||
| Address1: | 3051 WATSON BLVD | ||||||||
| Address2: | SUITE 525 | ||||||||
| City: | WARNER ROBINS | ||||||||
| State: | GA | ||||||||
| PostalCode: | 310938536 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4789534563 | ||||||||
| FaxNumber: | 4789534683 | ||||||||
| Practice Location | |||||||||
| Address1: | 3051 WATSON BLVD | ||||||||
| Address2: | SUITE 525 | ||||||||
| City: | WARNER ROBINS | ||||||||
| State: | GA | ||||||||
| PostalCode: | 310938536 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4789534563 | ||||||||
| FaxNumber: | 4789534683 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 04/27/2006 | ||||||||
| LastUpdateDate: | 08/13/2012 | ||||||||
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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 | 029514 | GA | Y | Allopathic & Osteopathic Physicians | Orthopaedic Surgery |
ID Information
| ID | Type | State | Issuer | Description | 00344627A | 05 | GA | MEDICAID |