Provider Demographics
NPI:1679571491
Name:PHILLIPS, CLYDE BENNETT (MD)
Entity type:Individual
Prefix:
First Name:CLYDE
Middle Name:BENNETT
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:PO BOX 1768
Mailing Address - Street 2:
Mailing Address - City:TUPELO
Mailing Address - State:MS
Mailing Address - Zip Code:38802-1768
Mailing Address - Country:US
Mailing Address - Phone:662-844-8699
Mailing Address - Fax:662-844-7087
Practice Address - Street 1:1464 MEDICAL PARK CIR
Practice Address - Street 2:
Practice Address - City:TUPELO
Practice Address - State:MS
Practice Address - Zip Code:38801-6595
Practice Address - Country:US
Practice Address - Phone:662-844-8699
Practice Address - Fax:662-844-7087
Is Sole Proprietor?:Yes
Enumeration Date:2005-07-14
Last Update Date:2009-01-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MS08406207X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207X00000XAllopathic & Osteopathic PhysiciansOrthopaedic Surgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
MS00010415Medicaid
2840610001OtherDMERC
P00007401OtherRAILROAD MEDICARE
D01010Medicare UPIN
MS00010415Medicaid