Provider Demographics
NPI:1366080475
Name:PHILLIPS, MADISON TAYLOR (MSW)
Entity type:Individual
Prefix:
First Name:MADISON
Middle Name:TAYLOR
Last Name:PHILLIPS
Suffix:
Gender:F
Credentials:MSW
Other - Prefix:
Other - First Name:MADISON
Other - Middle Name:
Other - Last Name:PHILLIPS
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:MSW
Mailing Address - Street 1:PO BOX 82
Mailing Address - Street 2:
Mailing Address - City:EHRENBERG
Mailing Address - State:AZ
Mailing Address - Zip Code:85334-0082
Mailing Address - Country:US
Mailing Address - Phone:619-857-6897
Mailing Address - Fax:
Practice Address - Street 1:15741 BERING ST
Practice Address - Street 2:
Practice Address - City:EHRENBERG
Practice Address - State:AZ
Practice Address - Zip Code:85334-0010
Practice Address - Country:US
Practice Address - Phone:619-857-6897
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2019-12-19
Last Update Date:2019-12-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA91820208D00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208D00000XAllopathic & Osteopathic PhysiciansGeneral Practice