Basic Information
| Provider Information | |||||||||
| NPI: | 1205027646 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | PHOENIX ID LLC | ||||||||
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| Mailing Information | |||||||||
| Address1: | 3303 S LINDSAY RD STE 123 | ||||||||
| Address2: | |||||||||
| City: | GILBERT | ||||||||
| State: | AZ | ||||||||
| PostalCode: | 852972100 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4808219339 | ||||||||
| FaxNumber: | 4808219555 | ||||||||
| Practice Location | |||||||||
| Address1: | 340 E PALM LN STE 100 | ||||||||
| Address2: | |||||||||
| City: | PHOENIX | ||||||||
| State: | AZ | ||||||||
| PostalCode: | 850044528 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6022541136 | ||||||||
| FaxNumber: | 6022721720 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 08/08/2007 | ||||||||
| LastUpdateDate: | 10/09/2008 | ||||||||
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| AuthorizedOfficialLastName: | OOMMEN | ||||||||
| AuthorizedOfficialFirstName: | JACOB | ||||||||
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| AuthorizedOfficialTitleorPosition: | OWNER | ||||||||
| AuthorizedOfficialTelephone: | 4809077786 | ||||||||
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| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialCredential: | MD | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207RI0200X | 37316 | AZ | Y | 193400000X SINGLE SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Internal Medicine | Infectious Disease |
No ID Information.