Basic Information
| Provider Information | |||||||||
| NPI: | 1962481044 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | PHILLIPS | ||||||||
| FirstName: | PAMELA | ||||||||
| MiddleName: | KIM | ||||||||
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| Credential: | MD | ||||||||
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| Mailing Information | |||||||||
| Address1: | 4513 WILLIAMS DR | ||||||||
| Address2: | |||||||||
| City: | GEORGETOWN | ||||||||
| State: | TX | ||||||||
| PostalCode: | 786331302 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5129303909 | ||||||||
| FaxNumber: | 5128695868 | ||||||||
| Practice Location | |||||||||
| Address1: | 2805 5TH ST | ||||||||
| Address2: | 100 | ||||||||
| City: | RAPID CITY | ||||||||
| State: | SD | ||||||||
| PostalCode: | 577017306 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6057555700 | ||||||||
| FaxNumber: | 6057553691 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 01/17/2006 | ||||||||
| LastUpdateDate: | 02/03/2022 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 02/03/2022 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207N00000X | S4216 | TX | N | Allopathic & Osteopathic Physicians | Dermatology | 207ND0101X | S4216 | TX | Y | Allopathic & Osteopathic Physicians | Dermatology | MOHS-Micrographic Surgery |
ID Information
| ID | Type | State | Issuer | Description | 473987600 | 05 | MN | MEDICAID |