MEDICARE: PHAETON HEALTH GROUP 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	2083X0100X	Occupational Medicine Physician	D0078360	MD
2	207Q00000X	Family Medicine Physician	D0070342	MD

General Provider Information

NPI Number	:	1790291003
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	PHAETON HEALTH GROUP LLC

Provider Business Mailing Address
First Line	:	518 S CAMP MEADE RD STE 1
Second Line	:
City	:	LINTHICUM HEIGHTS
State	:	MD
Zip	:	21090-2766
Country	:	US
Telephone Number	:	443-410-3325
Fax Number	:	443-960-4572

Provider Business Practice Location Address
First Line	:	518 S CAMP MEADE RD STE 1
Second Line	:
City	:	LINTHICUM HEIGHTS
State	:	MD
Zip	:	21090-2766
Country	:	US
Telephone Number	:	443-410-3325
Fax Number	:	443-960-4572

Authorized Official
Title or Position	:	CEO
Name	:	MICHAEL WILLIAMS
Credential	:	MD
Telephone Number	:	443-410-3325

Provider Enumeration Date	:	12/21/2017
Last Update Date	:	12/21/2017

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Directions to “PHAETON HEALTH GROUP LLC ” Practice Location

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