Provider Demographics
NPI:1215995360
Name:PHILLIPS, KENNETH E (DO)
Entity type:Individual
Prefix:
First Name:KENNETH
Middle Name:E
Last Name:PHILLIPS
Suffix:
Gender:M
Credentials:DO
Other - Prefix:
Other - First Name:KEN
Other - Middle Name:
Other - Last Name:PHILLIPS
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:DO
Mailing Address - Street 1:PO BOX 22063
Mailing Address - Street 2:DEPT 0491
Mailing Address - City:TULSA
Mailing Address - State:OK
Mailing Address - Zip Code:74121-2063
Mailing Address - Country:US
Mailing Address - Phone:405-751-4664
Mailing Address - Fax:405-749-4561
Practice Address - Street 1:6161 S YALE AVE
Practice Address - Street 2:ER DEPT
Practice Address - City:TULSA
Practice Address - State:OK
Practice Address - Zip Code:74136-1902
Practice Address - Country:US
Practice Address - Phone:918-494-6528
Practice Address - Fax:405-749-4561
Is Sole Proprietor?:No
Enumeration Date:2006-05-01
Last Update Date:2018-11-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ARE-10878207P00000X
OK3874207P00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207P00000XAllopathic & Osteopathic PhysiciansEmergency Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
OKP00199291OtherRR MEDICARE
OK100004840AMedicaid
OKH63868Medicare UPIN
OK100004840AMedicaid
OKP00199291OtherRR MEDICARE
OK244415604Medicare PIN