Healthcare Provider Details

I. General information

NPI: 1154898435
Provider Name (Legal Business Name): PHOENIX PHYSICIAN GROUP, PLLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 10/25/2018
Last Update Date: 07/03/2023
Certification Date: 07/03/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3430 N. MOUNTAIN RIDGE UNIT 14
MESA AZ
85207
US

IV. Provider business mailing address

2824 NORTH POWER ROAD, SUITE 113
MESA AZ
85215
US

V. Phone/Fax

Practice location:
  • Phone: 303-589-7881
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207PE0004X
TaxonomyEmergency Medical Services (Emergency Medicine) Physician
License Number
License Number State

VII. Legacy identifiers

For crosswalk purposes, the following legacy (non-NPI) identifiers are available for this provider:

VIII. Authorized Official

Name: TOM VO
Title or Position: CEO
Credential: M.D.
Phone: 713-660-0557