Provider Demographics
NPI:1366796567
Name:PHOENIX HEALTH CARE
Entity type:Organization
Organization Name:PHOENIX HEALTH CARE
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:GERALD
Authorized Official - Middle Name:
Authorized Official - Last Name:HUDSON
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:313-342-8421
Mailing Address - Street 1:10475 W JEFFERSON AVE
Mailing Address - Street 2:
Mailing Address - City:RIVER ROUGE
Mailing Address - State:MI
Mailing Address - Zip Code:48218-1331
Mailing Address - Country:US
Mailing Address - Phone:313-342-8421
Mailing Address - Fax:
Practice Address - Street 1:10475 W JEFFERSON AVE
Practice Address - Street 2:
Practice Address - City:RIVER ROUGE
Practice Address - State:MI
Practice Address - Zip Code:48218-1331
Practice Address - Country:US
Practice Address - Phone:313-342-8421
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2012-11-09
Last Update Date:2012-11-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI4301091092207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Single Specialty