MEDICARE: PHOENIX MEDICAL ASSOCIATES

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	2084A0401X	Addiction Medicine (Psychiatry & Neurology) Physician	G1112	TX

Medicare Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
2	CJ3940	OTHER	TX	RAILROAD MEDICARE
3	00564K	OTHER	TX	MEDICARE PTAN

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
4	0093CZ	OTHER	TX	BLUE CROSS BLUE SHIELD

General Provider Information

NPI Number	:	1790736239
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	PHOENIX MEDICAL ASSOCIATES

Provider Business Mailing Address
First Line	:	222 SIDNEY BAKER SOUTH
Second Line	:	SUITE 500
City	:	KERRVILLE
State	:	TX
Zip	:	78028-5900
Country	:	US
Telephone Number	:	830-895-7675
Fax Number	:	830-896-3082

Provider Business Practice Location Address
First Line	:	222 SIDNEY BAKER SOUTH
Second Line	:	SUITE 500
City	:	KERRVILLE
State	:	TX
Zip	:	78028-5900
Country	:	US
Telephone Number	:	830-895-7675
Fax Number	:	830-896-3082

Authorized Official
Title or Position	:	PRESIDENT
Name	:	ANAND W. MEHENDALE
Credential	:	M.D.
Telephone Number	:	830-895-7675

Provider Enumeration Date	:	05/12/2006
Last Update Date	:	09/08/2011

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Directions to “PHOENIX MEDICAL ASSOCIATES ” Practice Location

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