Provider Demographics
NPI:1790736239
Name:PHOENIX MEDICAL ASSOCIATES
Entity Type:Organization
Organization Name:PHOENIX MEDICAL ASSOCIATES
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:ANAND
Authorized Official - Middle Name:W
Authorized Official - Last Name:MEHENDALE
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:830-895-7675
Mailing Address - Street 1:222 SIDNEY BAKER SOUTH
Mailing Address - Street 2:SUITE 500
Mailing Address - City:KERRVILLE
Mailing Address - State:TX
Mailing Address - Zip Code:78028-5900
Mailing Address - Country:US
Mailing Address - Phone:830-895-7675
Mailing Address - Fax:830-896-3082
Practice Address - Street 1:222 SIDNEY BAKER SOUTH
Practice Address - Street 2:SUITE 500
Practice Address - City:KERRVILLE
Practice Address - State:TX
Practice Address - Zip Code:78028-5900
Practice Address - Country:US
Practice Address - Phone:830-895-7675
Practice Address - Fax:830-896-3082
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-05-12
Last Update Date:2011-09-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXG11122084A0401X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes2084A0401XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyAddiction MedicineGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX080790101Medicaid
TXCJ3940OtherRAILROAD MEDICARE
TX00564KOtherMEDICARE PTAN
TX0093CZOtherBLUE CROSS BLUE SHIELD
B24829Medicare UPIN