Provider Demographics
NPI:1992724595
Name:PHILLIPS, TIMOTHY MARTIN (MD)
Entity type:Individual
Prefix:DR
First Name:TIMOTHY
Middle Name:MARTIN
Last Name:PHILLIPS
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 1:1465 S GRAND BLVD
Mailing Address - Street 2:
Mailing Address - City:SAINT LOUIS
Mailing Address - State:MO
Mailing Address - Zip Code:63104-1003
Mailing Address - Country:US
Mailing Address - Phone:210-857-4174
Mailing Address - Fax:314-268-4176
Practice Address - Street 1:1465 S GRAND BLVD
Practice Address - Street 2:
Practice Address - City:SAINT LOUIS
Practice Address - State:MO
Practice Address - Zip Code:63104-1003
Practice Address - Country:US
Practice Address - Phone:210-857-4174
Practice Address - Fax:314-268-4176
Is Sole Proprietor?:No
Enumeration Date:2006-07-18
Last Update Date:2021-01-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXN65822088P0231X
MO20180107652088P0231X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2088P0231XAllopathic & Osteopathic PhysiciansUrologyPediatric Urology
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX286858001Medicaid
TXTXB142255Medicare PIN