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General NPI Number Information
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NPI Number | 1649470790
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Entity Type | Organization
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Legal Business Name | PHOENIX RISING MEDICAL, PC
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Dates
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Enumeration Date | 07/18/2007
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Last Update Date | 02/06/2025
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Provider Practice Location Address
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Address Line | 2829 WEHRLE DR STE 11A
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City | WILLIAMSVILLE
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State | NY
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Zip | 14221-7387
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Country | US
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Telephone | 716-458-0069
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Fax | 716-458-0061
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Provider Business Mailing Address
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Address Line | 2829 WEHRLE DR STE 11A
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City | WILLIAMSVILLE
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State | NY
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Zip | 14221-7387
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Country | US
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Telephone | 716-458-0069
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Fax | 716-458-0061
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Authorized Official
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Title or Position | OWNER
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Name | DR. TAJUDDIN M JIVA
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Credential | MD
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Telephone | 716-334-9879
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 207RP1001X
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Taxonomy Name | Pulmonary Disease Physician
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License Number | 183042
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License Number State | NY
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