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General NPI Number Information
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NPI Number | 1821591710
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Entity Type | Organization
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Legal Business Name | PHOENIXC HEALTHCARE, SC
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Dates
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Enumeration Date | 03/16/2018
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Last Update Date | 03/16/2018
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Provider Practice Location Address
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Address Line | 6121 GREEN BAY RD STE 100
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City | KENOSHA
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State | WI
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Zip | 53142-2931
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Country | US
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Telephone | 708-488-9515
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Fax |
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Provider Business Mailing Address
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Address Line | 11168 N LAKE SHORE DR
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City | MEQUON
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State | WI
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Zip | 53092-5811
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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 | PRESIDENT
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Name | INDRAJIT CHOUDHURI
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Credential | MD
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Telephone | 708-488-9515
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 207RC0001X
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Taxonomy Name | Clinical Cardiac Electrophysiology Physician
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License Number |
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License Number State |
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