Provider Demographics
NPI:1821591710
Name:PHOENIXC HEALTHCARE, SC
Entity Type:Organization
Organization Name:PHOENIXC HEALTHCARE, SC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:INDRAJIT
Authorized Official - Middle Name:
Authorized Official - Last Name:CHOUDHURI
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:708-488-9515
Mailing Address - Street 1:11168 N LAKE SHORE DR
Mailing Address - Street 2:
Mailing Address - City:MEQUON
Mailing Address - State:WI
Mailing Address - Zip Code:53092-5811
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:6121 GREEN BAY RD STE 100
Practice Address - Street 2:
Practice Address - City:KENOSHA
Practice Address - State:WI
Practice Address - Zip Code:53142-2931
Practice Address - Country:US
Practice Address - Phone:708-488-9515
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2018-03-16
Last Update Date:2018-03-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207RC0001XAllopathic & Osteopathic PhysiciansInternal MedicineClinical Cardiac ElectrophysiologyGroup - Single Specialty