Provider Demographics
NPI:1285617696
Name:PHILLIP, JOHN A (MD)
Entity type:Individual
Prefix:
First Name:JOHN
Middle Name:A
Last Name:PHILLIP
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 1:1524 ATWOOD AVE STE 245
Mailing Address - Street 2:
Mailing Address - City:JOHNSTON
Mailing Address - State:RI
Mailing Address - Zip Code:02919-3228
Mailing Address - Country:US
Mailing Address - Phone:401-443-5559
Mailing Address - Fax:401-443-5562
Practice Address - Street 1:1524 ATWOOD AVE
Practice Address - Street 2:SUITE 245
Practice Address - City:JOHNSTON
Practice Address - State:RI
Practice Address - Zip Code:02919-3228
Practice Address - Country:US
Practice Address - Phone:401-443-5559
Practice Address - Fax:401-443-5562
Is Sole Proprietor?:No
Enumeration Date:2005-11-21
Last Update Date:2023-12-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
RIRI08221208600000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208600000XAllopathic & Osteopathic PhysiciansSurgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
RI7002899Medicaid
RIRI08221OtherSTATE LICENSE #
RI1700281OtherUNITED HEALTHCARE #
RI004509OtherBLUE CHIP #
RIRI08221OtherSTATE LICENSE #