Provider Demographics
NPI:1487699716
Name:PHILLIPS, ELLEN D (MD)
Entity type:Individual
Prefix:
First Name:ELLEN
Middle Name:D
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 1:1118 ROSS CLARK CIR
Mailing Address - Street 2:SUITE 402
Mailing Address - City:DOTHAN
Mailing Address - State:AL
Mailing Address - Zip Code:36301-3001
Mailing Address - Country:US
Mailing Address - Phone:334-673-3633
Mailing Address - Fax:334-836-2893
Practice Address - Street 1:1118 ROSS CLARK CIR
Practice Address - Street 2:SUITE 402
Practice Address - City:DOTHAN
Practice Address - State:AL
Practice Address - Zip Code:36301-3001
Practice Address - Country:US
Practice Address - Phone:334-673-3633
Practice Address - Fax:334-836-2893
Is Sole Proprietor?:No
Enumeration Date:2006-06-19
Last Update Date:2009-07-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AL28733207V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207V00000XAllopathic & Osteopathic PhysiciansObstetrics & Gynecology
Provider Identifiers
StateIdentifier IDID TypeIssuer
AL009928965Medicaid
GA172534578AMedicaid
GA16BBCCZMedicare ID - Type Unspecified
GA172534578AMedicaid