MEDICARE: PHOENIX MEDICAL ASSOCIATES

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	207Q00000X	Family Medicine Physician	36100398	IL

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	4010133	OTHER	IL	ADVOCATE IL MASONIC ID
2	01629934	OTHER	IL	BCBS PROVIDER ID

General Provider Information

NPI Number	:	1043542525
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	PHOENIX MEDICAL ASSOCIATES

Provider Business Mailing Address
First Line	:	1777 W CRYSTAL LN
Second Line	:	APT 504
City	:	MT PROSPECT
State	:	IL
Zip	:	60056-5462
Country	:	US
Telephone Number	:	773-875-0185
Fax Number	:

Provider Business Practice Location Address
First Line	:	3716 N ASHLAND AVE
Second Line	:	SUITE 1
City	:	CHICAGO
State	:	IL
Zip	:	60613-3602
Country	:	US
Telephone Number	:	773-327-9900
Fax Number	:

Authorized Official
Title or Position	:	PRESIDENT/OWNER
Name	:	DR. FLORIAN MIRANZADEH
Credential	:	DO
Telephone Number	:	773-327-9000

Provider Enumeration Date	:	02/08/2010
Last Update Date	:	02/08/2010

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Directions to “PHOENIX MEDICAL ASSOCIATES ” Practice Location

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