Provider Demographics
NPI:1235229923
Name:PHOENIXVILLE SPECIALTY CLINICS, LLC
Entity Type:Organization
Organization Name:PHOENIXVILLE SPECIALTY CLINICS, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:VP PAYOR CONTRACTING
Authorized Official - Prefix:
Authorized Official - First Name:LUIS
Authorized Official - Middle Name:
Authorized Official - Last Name:ROSA
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:484-628-2099
Mailing Address - Street 1:4000 MERIDIAN BLVD
Mailing Address - Street 2:
Mailing Address - City:FRANKLIN
Mailing Address - State:TN
Mailing Address - Zip Code:37067-6325
Mailing Address - Country:US
Mailing Address - Phone:615-465-7000
Mailing Address - Fax:
Practice Address - Street 1:824 MAIN ST STE 306
Practice Address - Street 2:
Practice Address - City:PHOENIXVILLE
Practice Address - State:PA
Practice Address - Zip Code:19460-4478
Practice Address - Country:US
Practice Address - Phone:610-933-1133
Practice Address - Fax:610-933-4238
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-10-13
Last Update Date:2019-05-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes208800000XAllopathic & Osteopathic PhysiciansUrologyGroup - Multi-Specialty
No207V00000XAllopathic & Osteopathic PhysiciansObstetrics & GynecologyGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
PA1017628220001Medicaid
PA107858Medicare PIN