Provider Demographics
NPI:1033489109
Name:PHOENIX PSYCHIATRIC SERVICES
Entity Type:Organization
Organization Name:PHOENIX PSYCHIATRIC SERVICES
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:MS
Authorized Official - First Name:EWA
Authorized Official - Middle Name:M
Authorized Official - Last Name:CONROY
Authorized Official - Suffix:
Authorized Official - Credentials:APRN
Authorized Official - Phone:508-676-5514
Mailing Address - Street 1:3338 N MAIN ST
Mailing Address - Street 2:
Mailing Address - City:FALL RIVER
Mailing Address - State:MA
Mailing Address - Zip Code:02720-1609
Mailing Address - Country:US
Mailing Address - Phone:508-676-5514
Mailing Address - Fax:
Practice Address - Street 1:101 JEREMIAH SULLIVAN DR
Practice Address - Street 2:
Practice Address - City:FALL RIVER
Practice Address - State:MA
Practice Address - Zip Code:02721
Practice Address - Country:US
Practice Address - Phone:774-644-5629
Practice Address - Fax:508-678-8100
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2012-01-06
Last Update Date:2012-01-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MA206747261QM0850X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QM0850XAmbulatory Health Care FacilitiesClinic/CenterAdult Mental Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
MANP1932OtherMEDICARE B
MA0380130Medicaid
MANP1932OtherMEDICARE B