Provider Demographics
NPI:1992760698
Name:PHILLIPS, PAMELA MARTIN (MD)
Entity type:Individual
Prefix:
First Name:PAMELA
Middle Name:MARTIN
Last Name:PHILLIPS
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:PAMELA
Other - Middle Name:L
Other - Last Name:MARTIN
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:MD
Mailing Address - Street 1:PO BOX 11137
Mailing Address - Street 2:
Mailing Address - City:CHARLESTON
Mailing Address - State:WV
Mailing Address - Zip Code:25339-1137
Mailing Address - Country:US
Mailing Address - Phone:304-344-3457
Mailing Address - Fax:304-344-3480
Practice Address - Street 1:1120 KANAWHA BLVD E
Practice Address - Street 2:
Practice Address - City:CHARLESTON
Practice Address - State:WV
Practice Address - Zip Code:25301-2400
Practice Address - Country:US
Practice Address - Phone:304-344-3457
Practice Address - Fax:304-344-3480
Is Sole Proprietor?:No
Enumeration Date:2006-04-18
Last Update Date:2021-08-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WV192772085P0229X, 2085R0202X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2085R0202XAllopathic & Osteopathic PhysiciansRadiologyDiagnostic Radiology
No2085P0229XAllopathic & Osteopathic PhysiciansRadiologyPediatric Radiology
Provider Identifiers
StateIdentifier IDID TypeIssuer
VA7243898Medicaid
VA7243871Medicaid
VA7243880Medicaid
VA7243863Medicaid
WV0122386000Medicaid
VA6688-0024OtherCAREFIRST
VA7247371Medicaid
VA7243880Medicaid