Basic Information
| Provider Information | |||||||||
| NPI: | 1942234554 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | PHILLIPS | ||||||||
| FirstName: | MICHAEL | ||||||||
| MiddleName: | STEPHEN | ||||||||
| NamePrefix: | DR. | ||||||||
| NameSuffix: | |||||||||
| Credential: | M.D. | ||||||||
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| Mailing Information | |||||||||
| Address1: | 1301 W 7TH ST | ||||||||
| Address2: | SUITE # 121 | ||||||||
| City: | FT WORTH | ||||||||
| State: | TX | ||||||||
| PostalCode: | 761022651 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8173480425 | ||||||||
| FaxNumber: | 8177480455 | ||||||||
| Practice Location | |||||||||
| Address1: | 1301 W 7TH ST | ||||||||
| Address2: | SUITE # 121 | ||||||||
| City: | FT WORTH | ||||||||
| State: | TX | ||||||||
| PostalCode: | 761022651 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8173480425 | ||||||||
| FaxNumber: | 8177480425 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 07/10/2006 | ||||||||
| LastUpdateDate: | 09/15/2017 | ||||||||
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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 | 207Q00000X | E4598 | TX | N | Allopathic & Osteopathic Physicians | Family Medicine | 207VG0400X | E 4598 | TX | N | Allopathic & Osteopathic Physicians | Obstetrics & Gynecology | Gynecology | 208D00000X | E 4598 | TX | Y | Allopathic & Osteopathic Physicians | General Practice |
ID Information
| ID | Type | State | Issuer | Description | POQD231 | 05 | TX | MEDICAID |