Provider Demographics
NPI:1578119723
Name:PHOENIX INTEGRATED MEDICAL CENTER
Entity Type:Organization
Organization Name:PHOENIX INTEGRATED MEDICAL CENTER
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:MANAGER
Authorized Official - Prefix:DR
Authorized Official - First Name:TROY
Authorized Official - Middle Name:D
Authorized Official - Last Name:YEOMANS
Authorized Official - Suffix:
Authorized Official - Credentials:DC
Authorized Official - Phone:321-695-6747
Mailing Address - Street 1:890 N PHELPS AVE
Mailing Address - Street 2:
Mailing Address - City:WINTER PARK
Mailing Address - State:FL
Mailing Address - Zip Code:32789-2759
Mailing Address - Country:US
Mailing Address - Phone:321-695-6747
Mailing Address - Fax:
Practice Address - Street 1:2425 LEE RD
Practice Address - Street 2:
Practice Address - City:WINTER PARK
Practice Address - State:FL
Practice Address - Zip Code:32789-1747
Practice Address - Country:US
Practice Address - Phone:407-637-8300
Practice Address - Fax:407-637-8301
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2019-08-14
Last Update Date:2020-06-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerGroup - Multi-Specialty