Provider Demographics
NPI:1306894936
Name:PHILLIPS, CHARLES EDGAR (MD)
Entity type:Individual
Prefix:DR
First Name:CHARLES
Middle Name:EDGAR
Last Name:PHILLIPS
Suffix:
Gender:M
Credentials:MD
Other - Prefix:DR
Other - First Name:CHARLES
Other - Middle Name:E
Other - Last Name:PHILLIPS
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:MD
Mailing Address - Street 1:9601 LILE DR
Mailing Address - Street 2:
Mailing Address - City:LITTLE ROCK
Mailing Address - State:AR
Mailing Address - Zip Code:72205-6321
Mailing Address - Country:US
Mailing Address - Phone:501-227-5885
Mailing Address - Fax:501-227-5005
Practice Address - Street 1:9601 LILE DR
Practice Address - Street 2:
Practice Address - City:LITTLE ROCK
Practice Address - State:AR
Practice Address - Zip Code:72205-6321
Practice Address - Country:US
Practice Address - Phone:501-227-5885
Practice Address - Fax:501-227-5005
Is Sole Proprietor?:No
Enumeration Date:2006-05-05
Last Update Date:2007-10-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ARC4961207V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207V00000XAllopathic & Osteopathic PhysiciansObstetrics & Gynecology
Provider Identifiers
StateIdentifier IDID TypeIssuer
ARD08956Medicare UPIN