Basic Information
| Provider Information | |||||||||
| NPI: | 1629599287 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | PHILLIPS | ||||||||
| FirstName: | MICHELLE | ||||||||
| MiddleName: | NICOLE | ||||||||
| NamePrefix: | DR. | ||||||||
| NameSuffix: | |||||||||
| Credential: | MD | ||||||||
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| Mailing Information | |||||||||
| Address1: | 1 CHILDRENS WAY # 844 | ||||||||
| Address2: | |||||||||
| City: | LITTLE ROCK | ||||||||
| State: | AR | ||||||||
| PostalCode: | 722023500 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5013642090 | ||||||||
| FaxNumber: | 5013643929 | ||||||||
| Practice Location | |||||||||
| Address1: | 2601 GENE GEORGE BLVD | ||||||||
| Address2: | |||||||||
| City: | SPRINGDALE | ||||||||
| State: | AR | ||||||||
| PostalCode: | 72762 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4797256977 | ||||||||
| FaxNumber: | 4797256577 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 07/03/2017 | ||||||||
| LastUpdateDate: | 07/21/2022 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207P00000X | 25MA10164900 | NJ | N | Allopathic & Osteopathic Physicians | Emergency Medicine | 208000000X | E-10842 | AR | Y | Allopathic & Osteopathic Physicians | Pediatrics |
ID Information
| ID | Type | State | Issuer | Description | 224759001 | 05 | AR | MEDICAID |