Provider Demographics
NPI:1356433601
Name:MONROE, PHILLIP L (MD)
Entity type:Individual
Prefix:DR
First Name:PHILLIP
Middle Name:L
Last Name:MONROE
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 4046
Mailing Address - Street 2:
Mailing Address - City:SPRINGFIELD
Mailing Address - State:MO
Mailing Address - Zip Code:65808-4046
Mailing Address - Country:US
Mailing Address - Phone:417-269-2281
Mailing Address - Fax:417-883-5466
Practice Address - Street 1:2750 S CAMPBELL AVE
Practice Address - Street 2:
Practice Address - City:SPRINGFIELD
Practice Address - State:MO
Practice Address - Zip Code:65807-3506
Practice Address - Country:US
Practice Address - Phone:417-269-2281
Practice Address - Fax:417-883-5466
Is Sole Proprietor?:No
Enumeration Date:2006-09-28
Last Update Date:2015-08-05
Deactivation Date:2015-07-09
Deactivation Code:
Reactivation Date:2015-08-05
Provider Licenses
StateLicense IDTaxonomies
MOR2A46207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
10230OtherBLUE CROSS
MO201157617Medicaid
10230OtherBLUE CROSS
014175143Medicare PIN
A09909Medicare UPIN
MO201157617Medicaid
P00374622Medicare PIN