Provider Demographics
NPI:1306524152
Name:PHS AMBULATORY SERVICES LLC
Entity type:Organization
Organization Name:PHS AMBULATORY SERVICES LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:EVP GENERAL COUNSEL
Authorized Official - Prefix:
Authorized Official - First Name:STEPHEN
Authorized Official - Middle Name:
Authorized Official - Last Name:PETROVICH
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:615-296-3594
Mailing Address - Street 1:340 SEVEN SPRINGS WAY STE 100
Mailing Address - Street 2:
Mailing Address - City:BRENTWOOD
Mailing Address - State:TN
Mailing Address - Zip Code:37027-5697
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:2850 OLYMPUS DR
Practice Address - Street 2:
Practice Address - City:POCATELLO
Practice Address - State:ID
Practice Address - Zip Code:83201-2271
Practice Address - Country:US
Practice Address - Phone:208-239-2273
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:POCATELLO HEALTH SYSTEM, LLC
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2023-07-10
Last Update Date:2023-10-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QU0200XAmbulatory Health Care FacilitiesClinic/CenterUrgent Care