Basic Information
| Provider Information | |||||||||
| NPI: | 1689084477 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | PHIPPS | ||||||||
| FirstName: | BLAKE | ||||||||
| MiddleName: | GORDON | ||||||||
| NamePrefix: | DR. | ||||||||
| NameSuffix: | |||||||||
| Credential: | M.D. | ||||||||
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| Mailing Information | |||||||||
| Address1: | 4951 W 18TH ST | ||||||||
| Address2: | |||||||||
| City: | LAWRENCE | ||||||||
| State: | KS | ||||||||
| PostalCode: | 660472090 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7858416540 | ||||||||
| FaxNumber: | 7858413305 | ||||||||
| Practice Location | |||||||||
| Address1: | 4951 W 18TH ST | ||||||||
| Address2: | |||||||||
| City: | LAWRENCE | ||||||||
| State: | KS | ||||||||
| PostalCode: | 66047 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7858416540 | ||||||||
| FaxNumber: | 7858413305 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 05/01/2014 | ||||||||
| LastUpdateDate: | 08/22/2018 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | Y | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 390200000X | TX | N | Student, Health Care | Student in an Organized Health Care Education/Training Program | 207Q00000X | 0441094 | KS | Y | 193400000X SINGLE SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Family Medicine |
ID Information
| ID | Type | State | Issuer | Description | 201205020A | 05 | KS | MEDICAID |