Provider Demographics
NPI:1790249084
Name:TRUE PHOENIX COMMUNITY CARE, LLC
Entity Type:Organization
Organization Name:TRUE PHOENIX COMMUNITY CARE, LLC
Other - Org Name:TRUE PHOENIX
Other - Org Type:Doing Business As
Authorized Official - Title/Position:MEDICAL DIRECTOR
Authorized Official - Prefix:
Authorized Official - First Name:JINAYA
Authorized Official - Middle Name:S
Authorized Official - Last Name:BEATTY
Authorized Official - Suffix:
Authorized Official - Credentials:DNP, CRNP, FNP-BC
Authorized Official - Phone:443-793-7220
Mailing Address - Street 1:2316 E JOPPA RD FL 2
Mailing Address - Street 2:
Mailing Address - City:PARKVILLE
Mailing Address - State:MD
Mailing Address - Zip Code:21234-2808
Mailing Address - Country:US
Mailing Address - Phone:443-793-7220
Mailing Address - Fax:443-687-8705
Practice Address - Street 1:2316 E JOPPA RD FL 2
Practice Address - Street 2:
Practice Address - City:PARKVILLE
Practice Address - State:MD
Practice Address - Zip Code:21234-2808
Practice Address - Country:US
Practice Address - Phone:443-793-7220
Practice Address - Fax:443-687-8705
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2019-01-30
Last Update Date:2023-12-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes261QP2300XAmbulatory Health Care FacilitiesClinic/CenterPrimary CareGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
MD502149901Medicaid