Basic Information
| Provider Information | |||||||||
| NPI: | 1699786210 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | PHOENIX ANESTHESIA AND PAIN MANAGEMENT GROUP, PLLC | ||||||||
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| Mailing Information | |||||||||
| Address1: | 14902 PRESTON RD | ||||||||
| Address2: | SUITE 404-745 | ||||||||
| City: | DALLAS | ||||||||
| State: | TX | ||||||||
| PostalCode: | 752549191 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2144431240 | ||||||||
| FaxNumber: | 2144431240 | ||||||||
| Practice Location | |||||||||
| Address1: | 14902 PRESTON RD | ||||||||
| Address2: | SUITE 404-745 | ||||||||
| City: | DALLAS | ||||||||
| State: | TX | ||||||||
| PostalCode: | 752549191 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2144431240 | ||||||||
| FaxNumber: | 2144431240 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 08/10/2006 | ||||||||
| LastUpdateDate: | 12/21/2007 | ||||||||
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| AuthorizedOfficialLastName: | TAYLOR-KENNEDY | ||||||||
| AuthorizedOfficialFirstName: | LISA | ||||||||
| AuthorizedOfficialMiddleName: | C. | ||||||||
| AuthorizedOfficialTitleorPosition: | DIRECTOR | ||||||||
| AuthorizedOfficialTelephone: | 2144431240 | ||||||||
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| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialNamePrefix: | DR. | ||||||||
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| AuthorizedOfficialCredential: | MD | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207LP2900X | J2989 | TX | N | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Anesthesiology | Pain Medicine | 207L00000X | J2989 | TX | Y | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Anesthesiology |
ID Information
| ID | Type | State | Issuer | Description | BCBS FACILITY 0042HW | 01 | TX | LISA TAYLOR-KENNEDY, MD | OTHER | BCBS PROVIDER 8G0150 | 01 | TX | LISA TAYLOR-KENNEDY, MD | OTHER |