Basic Information
| Provider Information | |||||||||
| NPI: | 1679608095 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | PHOENIX HEART, PLLC | ||||||||
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| Mailing Information | |||||||||
| Address1: | 5859 W TALAVI BLVD STE 100 | ||||||||
| Address2: | |||||||||
| City: | GLENDALE | ||||||||
| State: | AZ | ||||||||
| PostalCode: | 853061870 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6022987777 | ||||||||
| FaxNumber: | 6239306060 | ||||||||
| Practice Location | |||||||||
| Address1: | 5859 W TALAVI BLVD STE 100 | ||||||||
| Address2: | |||||||||
| City: | GLENDALE | ||||||||
| State: | AZ | ||||||||
| PostalCode: | 853061870 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6022987777 | ||||||||
| FaxNumber: | 6239306060 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 02/23/2007 | ||||||||
| LastUpdateDate: | 03/11/2021 | ||||||||
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| AuthorizedOfficialLastName: | MUNHALL | ||||||||
| AuthorizedOfficialFirstName: | LYSA | ||||||||
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| AuthorizedOfficialTitleorPosition: | CREDENTIALING MANAGER | ||||||||
| AuthorizedOfficialTelephone: | 6022987777 | ||||||||
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| IsOrganizationSubpart: | N | ||||||||
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| NPICertificationDate: | 03/04/2021 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207RI0011X | N | 193400000X MULTIPLE SINGLE SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Internal Medicine | Interventional Cardiology | 207UN0901X | N | 193400000X MULTIPLE SINGLE SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Nuclear Medicine | Nuclear Cardiology | 363A00000X | N | 193400000X MULTIPLE SINGLE SPECIALTY GROUP | Physician Assistants & Advanced Practice Nursing Providers | Physician Assistant | 363LF0000X | N | 193400000X MULTIPLE SINGLE SPECIALTY GROUP | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner | Family | 363LG0600X | N | 193400000X MULTIPLE SINGLE SPECIALTY GROUP | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner | Gerontology | 207RC0000X | Y | 193400000X SINGLE SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Internal Medicine | Cardiovascular Disease |
ID Information
| ID | Type | State | Issuer | Description | Z27785 | 01 | AZ | MEDICARE PTAN | OTHER | Z212189 | 01 | AZ | MEDICARE PTAN | OTHER | 275622 | 05 | AZ | MEDICAID |