Basic Information
Provider Information | |||||||||
NPI: | 1982676664 | ||||||||
EntityType: | 1 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: |   | ||||||||
LastName: | PHILLPOTT | ||||||||
FirstName: | JUSTIN | ||||||||
MiddleName: | WESLEY | ||||||||
NamePrefix: | DR. | ||||||||
NameSuffix: |   | ||||||||
Credential: | M.D. | ||||||||
OtherOrganizationName: |   | ||||||||
OtherOrganizationType: |   | ||||||||
OtherLastName: |   | ||||||||
OtherFirstName: |   | ||||||||
OtherMiddleName: |   | ||||||||
OtherNamePrefix: |   | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: |   | ||||||||
OtherLastNameType: |   | ||||||||
Mailing Information | |||||||||
Address1: | 2055 NORMANDIE DR | ||||||||
Address2: | 108 | ||||||||
City: | MONTGOMERY | ||||||||
State: | AL | ||||||||
PostalCode: | 361112732 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 3342884624 | ||||||||
FaxNumber: | 3342803628 | ||||||||
Practice Location | |||||||||
Address1: | 2055 NORMANDIE DR | ||||||||
Address2: | 108 | ||||||||
City: | MONTGOMERY | ||||||||
State: | AL | ||||||||
PostalCode: | 361112732 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 3342884624 | ||||||||
FaxNumber: | 3342803628 | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 02/06/2006 | ||||||||
LastUpdateDate: | 11/02/2011 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: | M | ||||||||
AuthorizedOfficialLastName: |   | ||||||||
AuthorizedOfficialFirstName: |   | ||||||||
AuthorizedOfficialMiddleName: |   | ||||||||
AuthorizedOfficialTitleorPosition: |   | ||||||||
AuthorizedOfficialTelephone: |   | ||||||||
IsSoleProprietor: | Y | ||||||||
IsOrganizationSubpart: |   | ||||||||
ParentOrganizationLBN: |   | ||||||||
AuthorizedOfficialNamePrefix: |   | ||||||||
AuthorizedOfficialNameSuffix: |   | ||||||||
AuthorizedOfficialCredential: |   | ||||||||
NPICertificationDate: |   |
Taxonomy Information
Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 2085R0202X | 00026333 | AL | N |   | Allopathic & Osteopathic Physicians | Radiology | Diagnostic Radiology | 2085R0202X | ME76550 | FL | Y |   | Allopathic & Osteopathic Physicians | Radiology | Diagnostic Radiology | 2085R0202X | J8715 | TX | N |   | Allopathic & Osteopathic Physicians | Radiology | Diagnostic Radiology | 2085R0202X | 053805 | GA | N |   | Allopathic & Osteopathic Physicians | Radiology | Diagnostic Radiology | 2085R0204X | 00026333 | AL | N |   | Allopathic & Osteopathic Physicians | Radiology | Vascular & Interventional Radiology | 2085R0204X | ME76550 | FL | N |   | Allopathic & Osteopathic Physicians | Radiology | Vascular & Interventional Radiology | 2085R0204X | J8715 | TX | N |   | Allopathic & Osteopathic Physicians | Radiology | Vascular & Interventional Radiology | 2085R0204X | 053805 | GA | N |   | Allopathic & Osteopathic Physicians | Radiology | Vascular & Interventional Radiology |
ID Information
ID | Type | State | Issuer | Description | 107041 | 05 | AL |   | MEDICAID | 108373 | 05 | AL |   | MEDICAID | 107043 | 05 | AL |   | MEDICAID | 108074 | 05 | AL |   | MEDICAID |