Provider Demographics
NPI:1285637066
Name:PHOENIX OBSTETRICS AND GYNECOLOGY LLC
Entity Type:Organization
Organization Name:PHOENIX OBSTETRICS AND GYNECOLOGY LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OFFICER
Authorized Official - Prefix:
Authorized Official - First Name:KATHY
Authorized Official - Middle Name:
Authorized Official - Last Name:KONDAS
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:877-328-1119
Mailing Address - Street 1:5565 CENTERVIEW DR STE 107
Mailing Address - Street 2:
Mailing Address - City:RALEIGH
Mailing Address - State:NC
Mailing Address - Zip Code:27606-3563
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:919-425-0478
Practice Address - Street 1:1600 S ANDREWS AVE
Practice Address - Street 2:SUITE 323, WEST WING
Practice Address - City:FT LAUDERDALE
Practice Address - State:FL
Practice Address - Zip Code:33316-2510
Practice Address - Country:US
Practice Address - Phone:954-355-5110
Practice Address - Fax:919-425-0478
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2005-05-24
Last Update Date:2021-07-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLME43546207V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207V00000XAllopathic & Osteopathic PhysiciansObstetrics & GynecologyGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL269096900Medicaid
FL269096900Medicaid