Provider Demographics
NPI:1699849422
Name:PHOENIX CENTER INC
Entity Type:Organization
Organization Name:PHOENIX CENTER INC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:SHELLEY
Authorized Official - Middle Name:E
Authorized Official - Last Name:HAM
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:808-934-7355
Mailing Address - Street 1:PO BOX 10840
Mailing Address - Street 2:
Mailing Address - City:HILO
Mailing Address - State:HI
Mailing Address - Zip Code:96721-5840
Mailing Address - Country:US
Mailing Address - Phone:808-934-7355
Mailing Address - Fax:808-935-3209
Practice Address - Street 1:169 PUUEO ST
Practice Address - Street 2:
Practice Address - City:HILO
Practice Address - State:HI
Practice Address - Zip Code:96720-2432
Practice Address - Country:US
Practice Address - Phone:808-934-7355
Practice Address - Fax:808-935-3209
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-11-20
Last Update Date:2023-12-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
HILCSW32001041C0700X
HIMD89852084P0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes2084P0800XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyPsychiatryGroup - Single Specialty
No1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinicalGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
HIH51932Medicare PIN