Provider Demographics
NPI:1922381672
Name:NEW PHOENIX LLC
Entity Type:Organization
Organization Name:NEW PHOENIX LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER/PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:JAMES
Authorized Official - Middle Name:EUGENE
Authorized Official - Last Name:FOSTER
Authorized Official - Suffix:JR
Authorized Official - Credentials:MD
Authorized Official - Phone:937-299-8242
Mailing Address - Street 1:11161 ASHBURY MEADOWS DR
Mailing Address - Street 2:
Mailing Address - City:DAYTON
Mailing Address - State:OH
Mailing Address - Zip Code:45458-6403
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:3533 SOUTHERN BLVD
Practice Address - Street 2:STE 3000
Practice Address - City:KETTERING
Practice Address - State:OH
Practice Address - Zip Code:45429-1280
Practice Address - Country:US
Practice Address - Phone:937-299-8242
Practice Address - Fax:937-299-8245
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2011-09-20
Last Update Date:2018-01-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
OHH027071OtherMEDICARE PTAN