Healthcare Provider Details

I. General information

NPI: 1770087637
Provider Name (Legal Business Name): PHGTX INC.
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 03/23/2018
Last Update Date: 03/23/2018
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

211 E 7TH ST STE 620
AUSTIN TX
78701-3218
US

IV. Provider business mailing address

1515 NW 167TH ST STE 391
MIAMI GARDENS FL
33169-5100
US

V. Phone/Fax

Practice location:
  • Phone: 855-459-9958
  • Fax: 305-930-7435
Mailing address:
  • Phone: 855-459-9958
  • Fax: 305-930-7435

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code207QA0401X
TaxonomyAddiction Medicine (Family Medicine) Physician
License Number
License Number StateTX
# 2
Primary TaxonomyN
Taxonomy Code207RA0401X
TaxonomyAddiction Medicine (Internal Medicine) Physician
License Number
License Number StateTX
# 3
Primary TaxonomyY
Taxonomy Code261QR0405X
TaxonomySubstance Use Disorder Rehabilitation Clinic/Center
License Number
License Number State

VIII. Authorized Official

Name: MR. ROBERT NIZNIK
Title or Position: CEO
Credential:
Phone: 786-709-5442