Provider Demographics
NPI:1225111339
Name:PHOENIX MEDICAL GROUP PLLC
Entity Type:Organization
Organization Name:PHOENIX MEDICAL GROUP PLLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OFFICE MANAGER
Authorized Official - Prefix:
Authorized Official - First Name:KRISTINA
Authorized Official - Middle Name:
Authorized Official - Last Name:DARWIN
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:615-851-7811
Mailing Address - Street 1:740 CONFERENCE DR
Mailing Address - Street 2:SUITE 1
Mailing Address - City:GOODLETTSVILLE
Mailing Address - State:TN
Mailing Address - Zip Code:37072-1915
Mailing Address - Country:US
Mailing Address - Phone:615-851-7000
Mailing Address - Fax:615-851-7852
Practice Address - Street 1:740 CONFERENCE DR
Practice Address - Street 2:SUITE 1
Practice Address - City:GOODLETTSVILLE
Practice Address - State:TN
Practice Address - Zip Code:37072-1915
Practice Address - Country:US
Practice Address - Phone:615-851-7000
Practice Address - Fax:615-851-7852
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-10-23
Last Update Date:2008-02-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TN18477207R00000X
TNAPN0000012693363LA2200X
TN363L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal MedicineGroup - Multi-Specialty
No363LA2200XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerAdult HealthGroup - Multi-Specialty
No363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
TN3722529Medicare ID - Type UnspecifiedPHOENIX MEDICAL GROUP