Healthcare Provider Details

I. General information

NPI: 1164339065
Provider Name (Legal Business Name): PRIVATE HEALTH MANAGEMENT MEDICAL GROUP, PLLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 08/26/2026
Last Update Date: 08/26/2026
Certification Date: 08/26/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3800 N CENTRAL AVE STE 460
PHOENIX AZ
85012-1995
US

IV. Provider business mailing address

345 HERITAGE AVE # 1395
PORTSMOUTH NH
03801-5899
US

V. Phone/Fax

Practice location:
  • Phone: 213-275-0942
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code208D00000X
TaxonomyGeneral Practice Physician
License Number
License Number State

VIII. Authorized Official

Name: JOAQUIN FONG
Title or Position: CONTROLLER
Credential:
Phone: 213-275-0942