Basic Information
| Provider Information | |||||||||
| NPI: | 1558396580 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | PHOENIX MEDICAL ASSOCIATES, P.C. | ||||||||
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| Mailing Information | |||||||||
| Address1: | 777 OAKMONT LN | ||||||||
| Address2: | SUITE 1600 | ||||||||
| City: | WESTMONT | ||||||||
| State: | IL | ||||||||
| PostalCode: | 605595511 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6307892550 | ||||||||
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| Practice Location | |||||||||
| Address1: | 3718 N ASHLAND AVE | ||||||||
| Address2: | |||||||||
| City: | CHICAGO | ||||||||
| State: | IL | ||||||||
| PostalCode: | 606134793 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7733279900 | ||||||||
| FaxNumber: | 7733270589 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 07/11/2006 | ||||||||
| LastUpdateDate: | 02/23/2010 | ||||||||
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| AuthorizedOfficialLastName: | MIRANZADEH | ||||||||
| AuthorizedOfficialFirstName: | FLORIAN | ||||||||
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| AuthorizedOfficialTitleorPosition: | PRESIDENT / OWNER | ||||||||
| AuthorizedOfficialTelephone: | 7733279900 | ||||||||
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| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialCredential: | DO | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207Q00000X | 36100398 | IL | Y | 193400000X SINGLE SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Family Medicine |
ID Information
| ID | Type | State | Issuer | Description | 01629934 | 01 | IL | BCBS PROVIDER ID | OTHER | 4010133 | 01 | IL | ADVOCATE IL MASONIC ID | OTHER | 080171110 | 01 | IL | RAILROAD MEDICARE | OTHER |