Provider Demographics
NPI:1225549603
Name:DR PHILLIPS MEDICAL WELLNESS CENTER LLC
Entity type:Organization
Organization Name:DR PHILLIPS MEDICAL WELLNESS CENTER LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:MARYAM
Authorized Official - Middle Name:
Authorized Official - Last Name:PHILLIPS
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:407-900-0613
Mailing Address - Street 1:3300 S FISKE BLVD
Mailing Address - Street 2:
Mailing Address - City:ROCKLEDGE
Mailing Address - State:FL
Mailing Address - Zip Code:32955-4306
Mailing Address - Country:US
Mailing Address - Phone:407-960-1465
Mailing Address - Fax:407-335-6945
Practice Address - Street 1:2915 LAKEVIEW DR STE 1001
Practice Address - Street 2:
Practice Address - City:FERN PARK
Practice Address - State:FL
Practice Address - Zip Code:32730-2009
Practice Address - Country:US
Practice Address - Phone:407-900-0613
Practice Address - Fax:407-335-6945
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2017-10-12
Last Update Date:2021-03-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
FLNH873OtherFL MEDICARE
FLNH873OtherFL MEDICARE