Provider Demographics
NPI:1194994210
Name:PHILLIPS, TROY MAC (DO)
Entity type:Individual
Prefix:
First Name:TROY
Middle Name:MAC
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 1:2150 NC HIGHWAY 65
Mailing Address - Street 2:
Mailing Address - City:REIDSVILLE
Mailing Address - State:NC
Mailing Address - Zip Code:27320-9609
Mailing Address - Country:US
Mailing Address - Phone:336-427-9022
Mailing Address - Fax:
Practice Address - Street 1:2150 NC HIGHWAY 65
Practice Address - Street 2:
Practice Address - City:REIDSVILLE
Practice Address - State:NC
Practice Address - Zip Code:27320-9609
Practice Address - Country:US
Practice Address - Phone:336-427-9022
Practice Address - Fax:336-427-9030
Is Sole Proprietor?:No
Enumeration Date:2008-02-22
Last Update Date:2023-11-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SCTL1618207Q00000X
TXM8253207Q00000X
CO47984207Q00000X
NC2022-03210207Q00000X, 207QH0002X
SC1618207Q00000X, 207QH0002X, 208000000X
KS05-48528207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
No207QH0002XAllopathic & Osteopathic PhysiciansFamily MedicineHospice and Palliative Medicine
No208000000XAllopathic & Osteopathic PhysiciansPediatrics
Provider Identifiers
StateIdentifier IDID TypeIssuer
SC016182Medicaid
SCP01221638OtherRAILROAD MEDICARE
CO48220736Medicaid
SCAA98285019Medicare PIN
SCP01221638OtherRAILROAD MEDICARE
CO48220736Medicaid
COCO305392Medicare PIN
SC016182Medicaid