Provider Demographics
NPI:1114077187
Name:PHOENIX PET PARTNERS, LLC
Entity Type:Organization
Organization Name:PHOENIX PET PARTNERS, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:MICHAEL
Authorized Official - Middle Name:
Authorized Official - Last Name:LAWSON
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:602-331-1771
Mailing Address - Street 1:PO BOX 190
Mailing Address - Street 2:
Mailing Address - City:SIMI VALLEY
Mailing Address - State:CA
Mailing Address - Zip Code:93062-0190
Mailing Address - Country:US
Mailing Address - Phone:602-331-1771
Mailing Address - Fax:
Practice Address - Street 1:4540 E COTTON GIN LOOP
Practice Address - Street 2:STE 150
Practice Address - City:PHOENIX
Practice Address - State:AZ
Practice Address - Zip Code:85040-4820
Practice Address - Country:US
Practice Address - Phone:602-331-1771
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-01-11
Last Update Date:2010-07-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes2085R0202XAllopathic & Osteopathic PhysiciansRadiologyDiagnostic RadiologyGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
AZ219323Medicaid
Z117647Medicare PIN