1649784489 NPI number — PHOENIX AMERICAN MEDICAL LLC

Table of content: (NPI 1649784489)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1649784489 NPI number — PHOENIX AMERICAN MEDICAL LLC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
PHOENIX AMERICAN MEDICAL LLC
Provider Last Name:
Provider First Name:
Provider Middle Name:
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
Provider Gender Code:

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1649784489
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
11/13/2023
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
14690 SPRING HILL DR STE 101
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
SPRING HILL
Provider Business Mailing Address State Name:
FL
Provider Business Mailing Address Postal Code:
34609-8102
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
352-428-7817
Provider Business Mailing Address Fax Number:
352-797-2491

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
1030 S 78TH ST
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
TAMPA
Provider Business Practice Location Address State Name:
FL
Provider Business Practice Location Address Postal Code:
33619-4750
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
813-740-0646
Provider Business Practice Location Address Fax Number:
813-609-3733
Provider Enumeration Date:
11/30/2017

Additional Information

Authorized Official

Authorized Official Last Name:
MUFTAH
Authorized Official First Name:
AZZAM
Authorized Official Middle Name:
Authorized Official Title or Position:
OWNER
Authorized Official Telephone Number:
352-277-5348

Provider Taxonomy Codes

  • Taxonomy code: 207R00000X ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)

  • Identifier: 117185100 . This is a "Florida Medicaid Provider ID" identifier , issued by the state of ( FL ) . This identifiers is of the category "MEDICAID".




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