Provider Demographics
NPI:1992175582
Name:PHOENIX PRACTICE MANAGEMENT
Entity type:Organization
Organization Name:PHOENIX PRACTICE MANAGEMENT
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:MR
Authorized Official - First Name:REGAN
Authorized Official - Middle Name:
Authorized Official - Last Name:WILSON
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:404-492-8830
Mailing Address - Street 1:1266 W PACES FERRY RD NW
Mailing Address - Street 2:SUITE 339
Mailing Address - City:ATLANTA
Mailing Address - State:GA
Mailing Address - Zip Code:30327-2306
Mailing Address - Country:US
Mailing Address - Phone:404-492-8830
Mailing Address - Fax:
Practice Address - Street 1:1266 W PACES FERRY RD NW
Practice Address - Street 2:SUITE 339
Practice Address - City:ATLANTA
Practice Address - State:GA
Practice Address - Zip Code:30327-2306
Practice Address - Country:US
Practice Address - Phone:404-492-8830
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2015-09-25
Last Update Date:2015-09-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes332B00000XSuppliersDurable Medical Equipment & Medical Supplies