Provider Demographics
NPI:1285680645
Name:PHOENIX HEALTHCARE SERVICES LLC
Entity Type:Organization
Organization Name:PHOENIX HEALTHCARE SERVICES LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:DELEGATED OFFICIAL
Authorized Official - Prefix:DR
Authorized Official - First Name:JOEL
Authorized Official - Middle Name:
Authorized Official - Last Name:MOSTOW
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:773-465-4555
Mailing Address - Street 1:1941 GOVERNORS
Mailing Address - Street 2:
Mailing Address - City:HOFFMAN ESTATES
Mailing Address - State:IL
Mailing Address - Zip Code:60169
Mailing Address - Country:US
Mailing Address - Phone:847-310-3555
Mailing Address - Fax:773-751-2225
Practice Address - Street 1:7324 N WESTERN AVE
Practice Address - Street 2:
Practice Address - City:CHICAGO
Practice Address - State:IL
Practice Address - Zip Code:60645-1814
Practice Address - Country:US
Practice Address - Phone:773-465-4555
Practice Address - Fax:773-465-4552
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-05-26
Last Update Date:2008-04-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL103TP2701X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes103TP2701XBehavioral Health & Social Service ProvidersPsychologistGroup PsychotherapyGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL210467Medicare ID - Type Unspecified