Basic Information
| Provider Information | |||||||||
| NPI: | 1598757114 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | PHILLIPS | ||||||||
| FirstName: | WENDELL | ||||||||
| MiddleName: | B | ||||||||
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| Credential: | D.O. | ||||||||
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| Mailing Information | |||||||||
| Address1: | 2500 W UTOPIA RD | ||||||||
| Address2: | STE. 100 | ||||||||
| City: | PHOENIX | ||||||||
| State: | AZ | ||||||||
| PostalCode: | 850274171 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6022146148 | ||||||||
| FaxNumber: | 6022146149 | ||||||||
| Practice Location | |||||||||
| Address1: | 19636 N 27TH AVE | ||||||||
| Address2: | SUITE 308 | ||||||||
| City: | PHOENIX | ||||||||
| State: | AZ | ||||||||
| PostalCode: | 850274013 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6237801999 | ||||||||
| FaxNumber: | 6235160950 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 08/19/2005 | ||||||||
| LastUpdateDate: | 03/06/2020 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 03/06/2020 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207Q00000X | 2226 | AZ | N | Allopathic & Osteopathic Physicians | Family Medicine | 207QA0401X | 2226 | AZ | Y | Allopathic & Osteopathic Physicians | Family Medicine | Addiction Medicine |
ID Information
| ID | Type | State | Issuer | Description | 268715 | 05 | AZ | MEDICAID |