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NPI Code Detail

MEDICARE: PASSPORT HEALTH HOLDINGS LLC

MEDICARE: PASSPORT HEALTH HOLDINGS 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
12083P0901XPublic Health & General Preventive Medicine Physician
2261Q00000XClinic/CenterVA

General Provider Information

NPI Number : 1518397405
Entity Type Code : Organization
Provider Name (Legal Business Name) : PASSPORT HEALTH HOLDINGS LLC
Provider Business Mailing Address
First Line : 668 N 44TH ST
Second Line : SUITE 100W
City : PHOENIX
State : AZ
Zip : 85008-6507
Country : US
Telephone Number : 877-358-8648
Fax Number : 877-877-6875
Provider Business Practice Location Address
First Line : 400 N. CENTER DRIVE
Second Line : BUILDING 3 SUITE 108
City : NORFOLK
State : VA
Zip : 23502-0002
Country : US
Telephone Number : 877-358-8648
Fax Number : 877-877-6875
Authorized Official
Title or Position : CHIEF OPERATING OFFICER
Name : MR. PAUL FISHBURN
Credential :
Telephone Number : 480-646-9020
Provider Enumeration Date : 11/14/2013
Last Update Date : 04/01/2022

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Directions to “PASSPORT HEALTH HOLDINGS LLC ” Practice Location

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