Provider Demographics
NPI:1164918124
Name:ATHENA MEDICAL GROUP
Entity Type:Organization
Organization Name:ATHENA MEDICAL GROUP
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:MANAGING PARTNER
Authorized Official - Prefix:
Authorized Official - First Name:YANCEY
Authorized Official - Middle Name:SCOTT
Authorized Official - Last Name:GAITHER
Authorized Official - Suffix:
Authorized Official - Credentials:CEO
Authorized Official - Phone:480-712-8319
Mailing Address - Street 1:3083 S COTTONWOOD CT
Mailing Address - Street 2:
Mailing Address - City:CHANDLER
Mailing Address - State:AZ
Mailing Address - Zip Code:85286-2384
Mailing Address - Country:US
Mailing Address - Phone:623-810-3668
Mailing Address - Fax:
Practice Address - Street 1:16515 S 40TH ST STE 143
Practice Address - Street 2:
Practice Address - City:PHOENIX
Practice Address - State:AZ
Practice Address - Zip Code:85048-0560
Practice Address - Country:US
Practice Address - Phone:480-712-8319
Practice Address - Fax:480-712-1305
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2018-07-02
Last Update Date:2022-10-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207QA0505XAllopathic & Osteopathic PhysiciansFamily MedicineAdult MedicineGroup - Single Specialty