Provider Demographics
NPI:1790291003
Name:PHAETON HEALTH GROUP LLC
Entity Type:Organization
Organization Name:PHAETON HEALTH GROUP LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CEO
Authorized Official - Prefix:
Authorized Official - First Name:MICHAEL
Authorized Official - Middle Name:
Authorized Official - Last Name:WILLIAMS
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:443-410-3325
Mailing Address - Street 1:518 S CAMP MEADE RD STE 1
Mailing Address - Street 2:
Mailing Address - City:LINTHICUM HEIGHTS
Mailing Address - State:MD
Mailing Address - Zip Code:21090-2766
Mailing Address - Country:US
Mailing Address - Phone:443-410-3325
Mailing Address - Fax:443-960-4572
Practice Address - Street 1:518 S CAMP MEADE RD STE 1
Practice Address - Street 2:
Practice Address - City:LINTHICUM HEIGHTS
Practice Address - State:MD
Practice Address - Zip Code:21090-2766
Practice Address - Country:US
Practice Address - Phone:443-410-3325
Practice Address - Fax:443-960-4572
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2017-12-21
Last Update Date:2017-12-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MDD0070342207Q00000X
MDD00783602083X0100X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Multi-Specialty
No2083X0100XAllopathic & Osteopathic PhysiciansPreventive MedicineOccupational MedicineGroup - Multi-Specialty