Provider Demographics
NPI:1528090362
Name:PHILLIPS, ROBERT LEWIS SR (CRNA)
Entity type:Individual
Prefix:MR
First Name:ROBERT
Middle Name:LEWIS
Last Name:PHILLIPS
Suffix:SR
Gender:M
Credentials:CRNA
Other - Prefix:MR
Other - First Name:ROBERT
Other - Middle Name:LEWIS
Other - Last Name:PHILLIPS
Other - Suffix:SR
Other - Last Name Type:Other Name
Other - Credentials:CRNA
Mailing Address - Street 1:185 RIVER ROCK DR
Mailing Address - Street 2:
Mailing Address - City:ROCKY MOUNT
Mailing Address - State:VA
Mailing Address - Zip Code:24151-4069
Mailing Address - Country:US
Mailing Address - Phone:540-489-0839
Mailing Address - Fax:540-489-0839
Practice Address - Street 1:1970 ROANOKE BLVD
Practice Address - Street 2:
Practice Address - City:SALEM
Practice Address - State:VA
Practice Address - Zip Code:24153-6404
Practice Address - Country:US
Practice Address - Phone:540-982-2463
Practice Address - Fax:540-855-3464
Is Sole Proprietor?:Yes
Enumeration Date:2006-07-06
Last Update Date:2008-01-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA0001107282163W00000X
VA0024164244367500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes367500000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Anesthetist, Certified Registered
No163W00000XNursing Service ProvidersRegistered Nurse
Provider Identifiers
StateIdentifier IDID TypeIssuer
VA006201S48Medicare PIN