Healthcare Provider Details

I. General information

NPI: 1164918124
Provider Name (Legal Business Name): ATHENA MEDICAL GROUP
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 07/02/2018
Last Update Date: 08/20/2024
Certification Date: 08/20/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

16515 S 40TH ST STE 143
PHOENIX AZ
85048-0560
US

IV. Provider business mailing address

16515 S 40TH ST STE 143
PHOENIX AZ
85048-0560
US

V. Phone/Fax

Practice location:
  • Phone: 480-712-8319
  • Fax: 480-712-1305
Mailing address:
  • Phone: 480-712-8319
  • Fax: 480-712-1305

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207QA0505X
TaxonomyAdult Medicine Physician
License Number
License Number State

VIII. Authorized Official

Name: YANCEY SCOTT GAITHER
Title or Position: MANAGING PARTNER
Credential: CEO
Phone: 480-712-8319