Provider Demographics
NPI:1104974237
Name:PHILLIPS, JONATHAN S (DO)
Entity type:Individual
Prefix:
First Name:JONATHAN
Middle Name:S
Last Name:PHILLIPS
Suffix:
Gender:M
Credentials:DO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5515 PEACH ST
Mailing Address - Street 2:
Mailing Address - City:ERIE
Mailing Address - State:PA
Mailing Address - Zip Code:16509-2603
Mailing Address - Country:US
Mailing Address - Phone:814-868-8252
Mailing Address - Fax:814-868-8170
Practice Address - Street 1:5515 PEACH ST
Practice Address - Street 2:
Practice Address - City:ERIE
Practice Address - State:PA
Practice Address - Zip Code:16509-2603
Practice Address - Country:US
Practice Address - Phone:814-868-8252
Practice Address - Fax:814-868-8170
Is Sole Proprietor?:No
Enumeration Date:2007-01-08
Last Update Date:2008-09-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PAOS013373207R00000X
PAOS 0213373207P00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
No207P00000XAllopathic & Osteopathic PhysiciansEmergency Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
PA101891982Medicaid
PA110365Medicare PIN