Provider Demographics
NPI:1073139523
Name:PHOENIX VIRTUAL TELEHEALTH INCORPORATED
Entity Type:Organization
Organization Name:PHOENIX VIRTUAL TELEHEALTH INCORPORATED
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:STEPHANIE
Authorized Official - Middle Name:
Authorized Official - Last Name:FLOOD
Authorized Official - Suffix:
Authorized Official - Credentials:PA-C
Authorized Official - Phone:321-222-9287
Mailing Address - Street 1:PO BOX 974
Mailing Address - Street 2:
Mailing Address - City:HURLEY
Mailing Address - State:MS
Mailing Address - Zip Code:39555-0974
Mailing Address - Country:US
Mailing Address - Phone:321-222-9287
Mailing Address - Fax:830-255-5842
Practice Address - Street 1:7901 4TH STREET N, STE 300
Practice Address - Street 2:C/O REGISTERED AGENTS INC
Practice Address - City:ST PETERSBURG
Practice Address - State:FL
Practice Address - Zip Code:33702-4399
Practice Address - Country:US
Practice Address - Phone:321-222-9287
Practice Address - Fax:830-255-5842
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2020-06-21
Last Update Date:2020-06-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantGroup - Single Specialty