Basic Information
Provider Information | |||||||||
NPI: | 1518946771 | ||||||||
EntityType: | 1 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: |   | ||||||||
LastName: | COLLINS | ||||||||
FirstName: | PHILLIP | ||||||||
MiddleName: | B | ||||||||
NamePrefix: |   | ||||||||
NameSuffix: |   | ||||||||
Credential: | MD | ||||||||
OtherOrganizationName: |   | ||||||||
OtherOrganizationType: |   | ||||||||
OtherLastName: |   | ||||||||
OtherFirstName: |   | ||||||||
OtherMiddleName: |   | ||||||||
OtherNamePrefix: |   | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: |   | ||||||||
OtherLastNameType: |   | ||||||||
Mailing Information | |||||||||
Address1: | 10 ALICE PECK DAY DR | ||||||||
Address2: |   | ||||||||
City: | LEBANON | ||||||||
State: | NH | ||||||||
PostalCode: | 037662694 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 6034483121 | ||||||||
FaxNumber: | 6034487462 | ||||||||
Practice Location | |||||||||
Address1: | 127 MASCOMA ST | ||||||||
Address2: |   | ||||||||
City: | LEBANON | ||||||||
State: | NH | ||||||||
PostalCode: | 037662661 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 6034487459 | ||||||||
FaxNumber: | 6034487469 | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 01/16/2006 | ||||||||
LastUpdateDate: | 05/05/2017 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: | M | ||||||||
AuthorizedOfficialLastName: |   | ||||||||
AuthorizedOfficialFirstName: |   | ||||||||
AuthorizedOfficialMiddleName: |   | ||||||||
AuthorizedOfficialTitleorPosition: |   | ||||||||
AuthorizedOfficialTelephone: |   | ||||||||
IsSoleProprietor: | N | ||||||||
IsOrganizationSubpart: |   | ||||||||
ParentOrganizationLBN: |   | ||||||||
AuthorizedOfficialNamePrefix: |   | ||||||||
AuthorizedOfficialNameSuffix: |   | ||||||||
AuthorizedOfficialCredential: |   | ||||||||
NPICertificationDate: |   |
Taxonomy Information
Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 2083X0100X | 10496 | NH | Y |   | Allopathic & Osteopathic Physicians | Preventive Medicine | Occupational Medicine |
ID Information
ID | Type | State | Issuer | Description | 00039897 | 01 | VT | BLUE CROSS BLUE SHIELD VT | OTHER | COLL251643 | 01 | NH | ANTHEM NH | OTHER | 1008021 | 05 | VT |   | MEDICAID | 1518946771 | 01 | NH | MVP | OTHER | 30200260 | 05 | NH |   | MEDICAID |