Basic Information
| Provider Information | |||||||||
| NPI: | 1437143591 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | PHILLIPS | ||||||||
| FirstName: | ROBERT | ||||||||
| MiddleName: | LEROY | ||||||||
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| Credential: | MD | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 791128 | ||||||||
| Address2: | |||||||||
| City: | BALTIMORE | ||||||||
| State: | MD | ||||||||
| PostalCode: | 212791128 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7033912020 | ||||||||
| FaxNumber: | 7033911211 | ||||||||
| Practice Location | |||||||||
| Address1: | 3650 JOSEPH SIEWICK DR | ||||||||
| Address2: | STE 400 | ||||||||
| City: | FAIRFAX | ||||||||
| State: | VA | ||||||||
| PostalCode: | 220331710 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7033912020 | ||||||||
| FaxNumber: | 7033911211 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 09/06/2005 | ||||||||
| LastUpdateDate: | 10/17/2020 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 10/17/2020 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207Q00000X | 0101228279 | VA | Y | Allopathic & Osteopathic Physicians | Family Medicine |
ID Information
| ID | Type | State | Issuer | Description | 05646685 | 05 | VA | MEDICAID | P00026602 | 01 | RR MEDICARE | OTHER |