Provider Demographics
NPI:1306103353
Name:PHOENIX CM INCORPORATED
Entity type:Organization
Organization Name:PHOENIX CM INCORPORATED
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:EXECUTIVE DIRECTOR
Authorized Official - Prefix:MS
Authorized Official - First Name:ELLA
Authorized Official - Middle Name:B
Authorized Official - Last Name:RUSSELL
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:443-880-6124
Mailing Address - Street 1:52 TUSCAN WAY
Mailing Address - Street 2:STE. 202-142
Mailing Address - City:SAINT AUGUSTINE
Mailing Address - State:FL
Mailing Address - Zip Code:32092-1850
Mailing Address - Country:US
Mailing Address - Phone:904-201-9275
Mailing Address - Fax:
Practice Address - Street 1:52 TUSCAN WAY
Practice Address - Street 2:STE. 202-142
Practice Address - City:SAINT AUGUSTINE
Practice Address - State:FL
Practice Address - Zip Code:32092-1850
Practice Address - Country:US
Practice Address - Phone:904-201-9275
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2012-04-16
Last Update Date:2012-04-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes171M00000XOther Service ProvidersCase Manager/Care CoordinatorGroup - Multi-Specialty