Provider Demographics
NPI:1639494206
Name:PHOENIX DIAGNOSTIC MEDICAL GROUP, INC.
Entity Type:Organization
Organization Name:PHOENIX DIAGNOSTIC MEDICAL GROUP, INC.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:STEVEN
Authorized Official - Middle Name:
Authorized Official - Last Name:KAYE
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:310-871-3434
Mailing Address - Street 1:22361 PACIFIC COAST HWY # 441
Mailing Address - Street 2:
Mailing Address - City:MALIBU
Mailing Address - State:CA
Mailing Address - Zip Code:90265-4879
Mailing Address - Country:US
Mailing Address - Phone:310-871-3434
Mailing Address - Fax:
Practice Address - Street 1:20301 VENTURA BLVD STE 105
Practice Address - Street 2:
Practice Address - City:WOODLAND HILLS
Practice Address - State:CA
Practice Address - Zip Code:91364-2447
Practice Address - Country:US
Practice Address - Phone:310-871-3434
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2010-04-07
Last Update Date:2010-07-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAG29768208100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes208100000XAllopathic & Osteopathic PhysiciansPhysical Medicine & RehabilitationGroup - Single Specialty