Provider Demographics
NPI:1770919466
Name:PHOENIX MEDICAL OFFICE PLLC
Entity type:Organization
Organization Name:PHOENIX MEDICAL OFFICE PLLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:KYAWT
Authorized Official - Middle Name:THANDAR
Authorized Official - Last Name:AUNG
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:646-943-1588
Mailing Address - Street 1:19614 58TH AVE # 1F
Mailing Address - Street 2:
Mailing Address - City:FRESH MEADOWS
Mailing Address - State:NY
Mailing Address - Zip Code:11365-2306
Mailing Address - Country:US
Mailing Address - Phone:646-943-1588
Mailing Address - Fax:
Practice Address - Street 1:5223 VAN LOON ST
Practice Address - Street 2:
Practice Address - City:ELMHURST
Practice Address - State:NY
Practice Address - Zip Code:11373-4258
Practice Address - Country:US
Practice Address - Phone:646-943-1588
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2013-09-25
Last Update Date:2013-09-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY241558207RG0300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207RG0300XAllopathic & Osteopathic PhysiciansInternal MedicineGeriatric MedicineGroup - Single Specialty