Provider Demographics
NPI:1548270325
Name:ATWELL, PHYLLIS SAGE (MD)
Entity type:Individual
Prefix:
First Name:PHYLLIS
Middle Name:SAGE
Last Name:ATWELL
Suffix:
Gender:F
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:PO BOX 3559
Mailing Address - Street 2:
Mailing Address - City:BOONE
Mailing Address - State:NC
Mailing Address - Zip Code:28607-0859
Mailing Address - Country:US
Mailing Address - Phone:828-265-4370
Mailing Address - Fax:828-265-4354
Practice Address - Street 1:152 SOUTHGATE DR
Practice Address - Street 2:SUITE 3A
Practice Address - City:BOONE
Practice Address - State:NC
Practice Address - Zip Code:28607-4959
Practice Address - Country:US
Practice Address - Phone:828-265-4370
Practice Address - Fax:828-265-4354
Is Sole Proprietor?:Yes
Enumeration Date:2006-08-08
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC286092084P0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2084P0800XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyPsychiatry
Provider Identifiers
StateIdentifier IDID TypeIssuer
NC1068AOtherBCBS OF NC
NC40950OtherMEDCOST
NC891217KMedicaid
NC2209441Medicare ID - Type Unspecified
NC891217KMedicaid