Healthcare Provider Details

I. General information

NPI: 1487444212
Provider Name (Legal Business Name): PHOENIX MD INC.
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 05/06/2025
Last Update Date: 07/29/2025
Certification Date: 07/29/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

8150 CORPORATE PARK DR STE 200
CINCINNATI OH
45242-3360
US

IV. Provider business mailing address

770 KIPP DR
CINCINNATI OH
45255-4510
US

V. Phone/Fax

Practice location:
  • Phone: 888-926-6398
  • Fax: 888-702-0459
Mailing address:
  • Phone: 513-802-6551
  • Fax: 513-802-6551

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code261Q00000X
TaxonomyClinic/Center
License Number
License Number StateNULL
# 2
Primary TaxonomyN
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License Number
License Number StateNULL

VIII. Authorized Official

Name: CLINT CORNELL
Title or Position: PRESIDENT
Credential:
Phone: 513-802-6551