Provider Demographics
NPI: | 1992009864 |
---|---|
Name: | PHOENIX HEALTH CENTER, LLC |
Entity Type: | Organization |
Organization Name: | PHOENIX HEALTH CENTER, LLC |
Other - Org Name: | |
Other - Org Type: | |
Authorized Official - Title/Position: | EXECUTIVE VICE PRESIDENT |
Authorized Official - Prefix: | MR |
Authorized Official - First Name: | WILLIAM |
Authorized Official - Middle Name: | J |
Authorized Official - Last Name: | ROBY |
Authorized Official - Suffix: | |
Authorized Official - Credentials: | MBA |
Authorized Official - Phone: | 301-447-2360 |
Mailing Address - Street 1: | 101 KING ST |
Mailing Address - Street 2: | |
Mailing Address - City: | HAGERSTOWN |
Mailing Address - State: | MD |
Mailing Address - Zip Code: | 21740-5732 |
Mailing Address - Country: | US |
Mailing Address - Phone: | 301-447-2361 |
Mailing Address - Fax: | 301-447-3673 |
Practice Address - Street 1: | 101 KING ST |
Practice Address - Street 2: | |
Practice Address - City: | HAGERSTOWN |
Practice Address - State: | MD |
Practice Address - Zip Code: | 21740-5732 |
Practice Address - Country: | US |
Practice Address - Phone: | 301-447-2361 |
Practice Address - Fax: | 301-447-3673 |
EIN: | <UNAVAIL> |
Is Organization Subpart?: | No |
Parent Organization LBN: | |
Parent Organization TIN: | |
Enumeration Date: | 2011-01-06 |
Last Update Date: | 2011-01-06 |
Deactivation Date: | |
Deactivation Code: | |
Reactivation Date: |
Provider Licenses
State | License ID | Taxonomies |
---|---|---|
MD | 101YA0400X, 101YM0800X, 103TA0400X, 1041C0700X, 207QA0401X, 207RA0401X, 2084A0401X, 2084P0800X, 2084P0802X, 261QM0801X, 261QM0850X, 261QM2800X, 261QR0405X |
Provider Taxonomies
Primary? | Code | Type | Classification | Specialization | Group |
---|---|---|---|---|---|
Yes | 261QM2800X | Ambulatory Health Care Facilities | Clinic/Center | Methadone | Group - Multi-Specialty |
No | 101YA0400X | Behavioral Health & Social Service Providers | Counselor | Addiction (Substance Use Disorder) | Group - Multi-Specialty |
No | 101YM0800X | Behavioral Health & Social Service Providers | Counselor | Mental Health | Group - Multi-Specialty |
No | 103TA0400X | Behavioral Health & Social Service Providers | Psychologist | Addiction (Substance Use Disorder) | Group - Multi-Specialty |
No | 1041C0700X | Behavioral Health & Social Service Providers | Social Worker | Clinical | Group - Multi-Specialty |
No | 207QA0401X | Allopathic & Osteopathic Physicians | Family Medicine | Addiction Medicine | Group - Multi-Specialty |
No | 207RA0401X | Allopathic & Osteopathic Physicians | Internal Medicine | Addiction Medicine | Group - Multi-Specialty |
No | 2084A0401X | Allopathic & Osteopathic Physicians | Psychiatry & Neurology | Addiction Medicine | Group - Multi-Specialty |
No | 2084P0800X | Allopathic & Osteopathic Physicians | Psychiatry & Neurology | Psychiatry | Group - Multi-Specialty |
No | 2084P0802X | Allopathic & Osteopathic Physicians | Psychiatry & Neurology | Addiction Psychiatry | Group - Multi-Specialty |
No | 261QM0801X | Ambulatory Health Care Facilities | Clinic/Center | Mental Health (Including Community Mental Health Center) | Group - Multi-Specialty |
No | 261QM0850X | Ambulatory Health Care Facilities | Clinic/Center | Adult Mental Health | Group - Multi-Specialty |
No | 261QR0405X | Ambulatory Health Care Facilities | Clinic/Center | Rehabilitation, Substance Use Disorder |
Provider Identifiers
State | Identifier ID | ID Type | Issuer |
---|---|---|---|
MD | PENDING | Medicaid |