Provider Demographics
NPI:1598195489
Name:PASSPORT HEALTH HOLDINGS LLC
Entity Type:Organization
Organization Name:PASSPORT HEALTH HOLDINGS LLC
Other - Org Name:PPH OHIO LLC
Other - Org Type:Former Legal Business Name
Authorized Official - Title/Position:CHIEF OPERATING OFFICER
Authorized Official - Prefix:MR
Authorized Official - First Name:PAUL
Authorized Official - Middle Name:
Authorized Official - Last Name:FISHBURN
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:480-646-9020
Mailing Address - Street 1:668 N 44TH ST
Mailing Address - Street 2:SUITE 100W
Mailing Address - City:PHOENIX
Mailing Address - State:AZ
Mailing Address - Zip Code:85008-6507
Mailing Address - Country:US
Mailing Address - Phone:877-358-8648
Mailing Address - Fax:877-877-6875
Practice Address - Street 1:5890 SAWMILL RD
Practice Address - Street 2:SUITE 100
Practice Address - City:DUBLIN
Practice Address - State:OH
Practice Address - Zip Code:43017-1902
Practice Address - Country:US
Practice Address - Phone:877-358-8648
Practice Address - Fax:877-877-6875
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2013-11-14
Last Update Date:2022-04-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
2083P0901X, 261Q00000X
OH261Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes2083P0901XAllopathic & Osteopathic PhysiciansPreventive MedicinePublic Health & General Preventive MedicineGroup - Single Specialty
No261Q00000XAmbulatory Health Care FacilitiesClinic/CenterGroup - Single Specialty