Basic Information
| Provider Information | |||||||||
| NPI: | 1922381672 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | NEW PHOENIX LLC | ||||||||
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| Mailing Information | |||||||||
| Address1: | 11161 ASHBURY MEADOWS DR | ||||||||
| Address2: | |||||||||
| City: | DAYTON | ||||||||
| State: | OH | ||||||||
| PostalCode: | 454586403 | ||||||||
| CountryCode: | US | ||||||||
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| Practice Location | |||||||||
| Address1: | 3533 SOUTHERN BLVD | ||||||||
| Address2: | STE 3000 | ||||||||
| City: | KETTERING | ||||||||
| State: | OH | ||||||||
| PostalCode: | 454291280 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9372998242 | ||||||||
| FaxNumber: | 9372998245 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 09/20/2011 | ||||||||
| LastUpdateDate: | 01/19/2018 | ||||||||
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| AuthorizedOfficialLastName: | FOSTER | ||||||||
| AuthorizedOfficialFirstName: | JAMES | ||||||||
| AuthorizedOfficialMiddleName: | EUGENE | ||||||||
| AuthorizedOfficialTitleorPosition: | OWNER/PRESIDENT | ||||||||
| AuthorizedOfficialTelephone: | 9372998242 | ||||||||
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| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialNameSuffix: | JR. | ||||||||
| AuthorizedOfficialCredential: | M.D. | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207Q00000X | Y | 193400000X SINGLE SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Family Medicine |
ID Information
| ID | Type | State | Issuer | Description | H027071 | 01 | OH | MEDICARE PTAN | OTHER |