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General NPI Number Information
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NPI Number | 1164339065
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Entity Type | Organization
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Legal Business Name | PRIVATE HEALTH MANAGEMENT MEDICAL GROUP, PLLC
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Dates
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Enumeration Date | 08/26/2026
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Last Update Date | 08/26/2026
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Provider Practice Location Address
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Address Line | 3800 N CENTRAL AVE STE 460
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City | PHOENIX
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State | AZ
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Zip | 85012-1995
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Country | US
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Telephone | 213-275-0942
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Fax |
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Provider Business Mailing Address
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Address Line | 345 HERITAGE AVE # 1395
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City | PORTSMOUTH
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State | NH
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Zip | 03801-5899
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Country | US
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Telephone |
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Fax |
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Authorized Official
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Title or Position | CONTROLLER
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Name | JOAQUIN FONG
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Credential |
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Telephone | 213-275-0942
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 208D00000X
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Taxonomy Name | General Practice Physician
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License Number |
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License Number State |
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