MEDICARE: PHOENIX OBSTETRICS AND GYNECOLOGY LLC

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	207V00000X	Obstetrics & Gynecology Physician	ME43546	FL

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program

General Provider Information

NPI Number	:	1285637066
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	PHOENIX OBSTETRICS AND GYNECOLOGY LLC

Provider Business Mailing Address
First Line	:	5565 CENTERVIEW DR STE 107
Second Line	:
City	:	RALEIGH
State	:	NC
Zip	:	27606-3563
Country	:	US
Telephone Number	:
Fax Number	:	919-425-0478

Provider Business Practice Location Address
First Line	:	1600 S ANDREWS AVE
Second Line	:	SUITE 323, WEST WING
City	:	FT LAUDERDALE
State	:	FL
Zip	:	33316-2510
Country	:	US
Telephone Number	:	954-355-5110
Fax Number	:	919-425-0478

Authorized Official
Title or Position	:	OFFICER
Name	:	KATHY KONDAS
Credential	:
Telephone Number	:	877-328-1119

Provider Enumeration Date	:	05/24/2005
Last Update Date	:	07/15/2021

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Directions to “PHOENIX OBSTETRICS AND GYNECOLOGY LLC ” Practice Location

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