MEDICARE: PASSPORT HEALTH HOLDINGS, LLC

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	2083P0901X	Public Health & General Preventive Medicine Physician	261Q0000X	NV

General Provider Information

NPI Number	:	1467878595
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	PASSPORT HEALTH HOLDINGS, LLC

Provider Business Mailing Address
First Line	:	668 N 44TH ST
Second Line	:	SUITE 100W
City	:	PHOENIX
State	:	AZ
Zip	:	85008-6507
Country	:	US
Telephone Number	:	877-358-8648
Fax Number	:	877-877-6875

Provider Business Practice Location Address
First Line	:	8766 S. MARYLAND PKWY
Second Line	:	SUITE 104
City	:	LAS VEGAS
State	:	NV
Zip	:	89123-6700
Country	:	US
Telephone Number	:	877-358-8648
Fax Number	:	877-877-6875

Authorized Official
Title or Position	:	CHIEF OPERATING OFFICER
Name	:	MR. PAUL FISHBURN
Credential	:
Telephone Number	:	480-646-9020

Provider Enumeration Date	:	03/13/2014
Last Update Date	:	04/01/2022

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