Basic Information
| Provider Information | |||||||||
| NPI: | 1518961580 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | PHILLIPS | ||||||||
| FirstName: | JOHN | ||||||||
| MiddleName: | KENNETH | ||||||||
| NamePrefix: | DR. | ||||||||
| NameSuffix: | |||||||||
| Credential: | M.D. | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 1960 | ||||||||
| Address2: | PO BOX 1960 | ||||||||
| City: | JONESBORO | ||||||||
| State: | AR | ||||||||
| PostalCode: | 724031960 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8709368000 | ||||||||
| FaxNumber: | 8709361043 | ||||||||
| Practice Location | |||||||||
| Address1: | 3024 STADIUM BLVD | ||||||||
| Address2: | |||||||||
| City: | JONESBORO | ||||||||
| State: | AR | ||||||||
| PostalCode: | 724017415 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8709345113 | ||||||||
| FaxNumber: | 8703923608 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 06/08/2005 | ||||||||
| LastUpdateDate: | 12/01/2016 | ||||||||
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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 | 2085R0202X | E0129 | AR | Y | Allopathic & Osteopathic Physicians | Radiology | Diagnostic Radiology |
ID Information
| ID | Type | State | Issuer | Description | 208891804 | 05 | MO | MEDICAID | 129236001 | 05 | AR | MEDICAID |