MEDICARE: PHOENIX

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	251V00000X	Voluntary or Charitable Agency

General Provider Information

NPI Number	:	1972118438
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	PHOENIX

Provider Business Mailing Address
First Line	:	6697 ELM ST
Second Line	:
City	:	NORTH BRANCH
State	:	MN
Zip	:	55056-7045
Country	:	US
Telephone Number	:	651-795-8759
Fax Number	:

Provider Business Practice Location Address
First Line	:	6697 ELM ST
Second Line	:
City	:	NORTH BRANCH
State	:	MN
Zip	:	55056-7045
Country	:	US
Telephone Number	:	651-795-8759
Fax Number	:

Authorized Official
Title or Position	:	CO-FOUNDER
Name	:	JEREMY JAMES KORTUS
Credential	:
Telephone Number	:	651-795-8759

Provider Enumeration Date	:	09/11/2020
Last Update Date	:	09/11/2020

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Directions to “PHOENIX ” Practice Location

Language	Start Address	Practice Location

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