Healthcare Provider Details

I. General information

NPI: 1790291003
Provider Name (Legal Business Name): PHAETON HEALTH GROUP LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 12/21/2017
Last Update Date: 12/21/2017
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

518 S CAMP MEADE RD STE 1
LINTHICUM HEIGHTS MD
21090-2766
US

IV. Provider business mailing address

518 S CAMP MEADE RD STE 1
LINTHICUM HEIGHTS MD
21090-2766
US

V. Phone/Fax

Practice location:
  • Phone: 443-410-3325
  • Fax: 443-960-4572
Mailing address:
  • Phone: 443-410-3325
  • Fax: 443-960-4572

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License NumberD0070342
License Number StateMD
# 2
Primary TaxonomyN
Taxonomy Code2083X0100X
TaxonomyOccupational Medicine Physician
License NumberD0078360
License Number StateMD

VIII. Authorized Official

Name: MICHAEL WILLIAMS
Title or Position: CEO
Credential: MD
Phone: 443-410-3325