Provider Demographics
NPI:1558823500
Name:PHOENIX INTERNAL MEDICINE LLC
Entity Type:Organization
Organization Name:PHOENIX INTERNAL MEDICINE LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:ROBERT
Authorized Official - Middle Name:
Authorized Official - Last Name:POWERS
Authorized Official - Suffix:
Authorized Official - Credentials:DO
Authorized Official - Phone:407-906-5092
Mailing Address - Street 1:127 W FAIRBANKS AVE # 374
Mailing Address - Street 2:
Mailing Address - City:WINTER PARK
Mailing Address - State:FL
Mailing Address - Zip Code:32789-4326
Mailing Address - Country:US
Mailing Address - Phone:407-906-5092
Mailing Address - Fax:407-641-8133
Practice Address - Street 1:5579 S ORANGE AVE
Practice Address - Street 2:
Practice Address - City:EDGEWOOD
Practice Address - State:FL
Practice Address - Zip Code:32809-3493
Practice Address - Country:US
Practice Address - Phone:407-906-5092
Practice Address - Fax:407-641-8133
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2019-04-01
Last Update Date:2020-10-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes208M00000XAllopathic & Osteopathic PhysiciansHospitalistGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL003812400Medicaid