Basic Information
| Provider Information | |||||||||
| NPI: | 1477747582 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | PHILLIPS | ||||||||
| FirstName: | JUSTIN | ||||||||
| MiddleName: | D | ||||||||
| NamePrefix: | DR. | ||||||||
| NameSuffix: | |||||||||
| Credential: | MD | ||||||||
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| Mailing Information | |||||||||
| Address1: | P.O. BOX 9150 | ||||||||
| Address2: | |||||||||
| City: | PADUCAH | ||||||||
| State: | KY | ||||||||
| PostalCode: | 420029150 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2707449600 | ||||||||
| FaxNumber: | 2707440834 | ||||||||
| Practice Location | |||||||||
| Address1: | 2 ST. VINCENT CIRCLE | ||||||||
| Address2: | |||||||||
| City: | LITTLE ROCK | ||||||||
| State: | AR | ||||||||
| PostalCode: | 722055423 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5015523000 | ||||||||
| FaxNumber: | 5015524181 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 08/31/2007 | ||||||||
| LastUpdateDate: | 10/14/2013 | ||||||||
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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 | 207P00000X | E5814 | AR | N | Allopathic & Osteopathic Physicians | Emergency Medicine | 207P00000X | P6061 | TX | Y | Allopathic & Osteopathic Physicians | Emergency Medicine |
ID Information
| ID | Type | State | Issuer | Description | P01198742 | 01 | TX | MEDICARE RAILROAD | OTHER | 180290001 | 05 | AR | MEDICAID | 317651301 | 05 | TX | MEDICAID | 1477747582 | 01 | AR | BCBS | OTHER | 317651302 | 05 | TX | MEDICAID | 317651303 | 05 | TX | MEDICAID |