Basic Information
| Provider Information | |||||||||
| NPI: | 1841281995 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | PHILLIPS | ||||||||
| FirstName: | BENJAMIN | ||||||||
| MiddleName: | R. | ||||||||
| NamePrefix: | DR. | ||||||||
| NameSuffix: | |||||||||
| Credential: | M.D. | ||||||||
| OtherOrganizationName: | |||||||||
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| Mailing Information | |||||||||
| Address1: | 1100 WALNUT ST | ||||||||
| Address2: | MOB, 5TH FLOOR | ||||||||
| City: | PHILADELPHIA | ||||||||
| State: | PA | ||||||||
| PostalCode: | 191075563 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2159556750 | ||||||||
| FaxNumber: | 2159238222 | ||||||||
| Practice Location | |||||||||
| Address1: | 1100 WALNUT ST | ||||||||
| Address2: | MOB, 5TH FLOOR | ||||||||
| City: | PHILADELPHIA | ||||||||
| State: | PA | ||||||||
| PostalCode: | 191075563 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2159556750 | ||||||||
| FaxNumber: | 2159238222 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 10/28/2005 | ||||||||
| LastUpdateDate: | 12/14/2012 | ||||||||
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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 | 208600000X | 2005-01072 | NC | N | Allopathic & Osteopathic Physicians | Surgery | 208600000X | 25MA08649700 | NJ | N | Allopathic & Osteopathic Physicians | Surgery | 208C00000X | MA08649700 | NJ | N | Allopathic & Osteopathic Physicians | Colon & Rectal Surgery | 208C00000X | MD433750 | PA | Y | Allopathic & Osteopathic Physicians | Colon & Rectal Surgery |
ID Information
| ID | Type | State | Issuer | Description | 5901864 | 05 | NC | MEDICAID | MA08649700 | 01 | NJ | STATE LICENSE | OTHER |