Provider Demographics
NPI:1679971097
Name:PHOENIX HEALTH CENTER LLC
Entity type:Organization
Organization Name:PHOENIX HEALTH CENTER LLC
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:CEO
Authorized Official - Prefix:
Authorized Official - First Name:JAY
Authorized Official - Middle Name:
Authorized Official - Last Name:HIGHAM
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:214-365-6112
Mailing Address - Street 1:5001 SPRING VALLEY ROAD
Mailing Address - Street 2:SUITE 600 EAST
Mailing Address - City:DALLAS
Mailing Address - State:TX
Mailing Address - Zip Code:75244-3946
Mailing Address - Country:US
Mailing Address - Phone:214-365-6100
Mailing Address - Fax:214-365-6150
Practice Address - Street 1:217 E ANTIETAM ST
Practice Address - Street 2:
Practice Address - City:HAGERSTOWN
Practice Address - State:MD
Practice Address - Zip Code:21740-5724
Practice Address - Country:US
Practice Address - Phone:240-420-0000
Practice Address - Fax:240-420-0002
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2014-12-17
Last Update Date:2024-12-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
261QM0801X, 261QR0405X
MDMD10126M261QM2800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QM2800XAmbulatory Health Care FacilitiesClinic/CenterMethadone
No261QM0801XAmbulatory Health Care FacilitiesClinic/CenterMental Health (Including Community Mental Health Center)
No261QR0405XAmbulatory Health Care FacilitiesClinic/CenterRehabilitation, Substance Use Disorder
Provider Identifiers
StateIdentifier IDID TypeIssuer
MD330305500Medicaid