Provider Demographics
NPI:1194710194
Name:PHILLIPS, DAN EMORY (MD)
Entity type:Individual
Prefix:DR
First Name:DAN
Middle Name:EMORY
Last Name:PHILLIPS
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 4947
Mailing Address - Street 2:
Mailing Address - City:MACON
Mailing Address - State:GA
Mailing Address - Zip Code:31208-4947
Mailing Address - Country:US
Mailing Address - Phone:478-301-2362
Mailing Address - Fax:478-301-2272
Practice Address - Street 1:250 MARTIN LUTHER KING JR BLVD
Practice Address - Street 2:
Practice Address - City:MACON
Practice Address - State:GA
Practice Address - Zip Code:31201
Practice Address - Country:US
Practice Address - Phone:478-301-4111
Practice Address - Fax:478-301-5812
Is Sole Proprietor?:No
Enumeration Date:2005-09-15
Last Update Date:2014-07-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PAMD067225L2084P0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2084P0800XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyPsychiatry
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA320705169AMedicaid
I65522Medicare UPIN