Provider Demographics
NPI:1558321653
Name:PHILLIPS, MELODIE (MD)
Entity type:Individual
Prefix:
First Name:MELODIE
Middle Name:
Last Name:PHILLIPS
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 1:3009 SMITH RD
Mailing Address - Street 2:
Mailing Address - City:FAIRLAWN
Mailing Address - State:OH
Mailing Address - Zip Code:44333-2666
Mailing Address - Country:US
Mailing Address - Phone:330-665-4488
Mailing Address - Fax:330-665-4489
Practice Address - Street 1:3009 SMITH RD
Practice Address - Street 2:
Practice Address - City:FAIRLAWN
Practice Address - State:OH
Practice Address - Zip Code:44333-2666
Practice Address - Country:US
Practice Address - Phone:330-665-4488
Practice Address - Fax:330-665-4489
Is Sole Proprietor?:No
Enumeration Date:2006-03-24
Last Update Date:2020-10-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH35-052393P207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH0706230Medicaid
OH110140131OtherRAILROAD MEDICARE
OH492OtherSUMMACARE
OHPH0653555OtherMEDICARE PTAN PH0653555
OH000000132182OtherANTHEM
OH729763OtherBUCKEYE COMMUNITY HEALTH
OH110140131OtherRAILROAD MEDICARE