Provider Demographics
NPI:1447861950
Name:PHYNOVA MSO, LLC
Entity type:Organization
Organization Name:PHYNOVA MSO, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CHIEF EXECUTIVE OFFICER
Authorized Official - Prefix:
Authorized Official - First Name:LAVERNE
Authorized Official - Middle Name:W
Authorized Official - Last Name:POINDEXTER
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:770-270-5229
Mailing Address - Street 1:PO BOX 54157
Mailing Address - Street 2:
Mailing Address - City:ATLANTA
Mailing Address - State:GA
Mailing Address - Zip Code:30308-0157
Mailing Address - Country:US
Mailing Address - Phone:770-270-5229
Mailing Address - Fax:770-270-9323
Practice Address - Street 1:1718 PEACHTREE ST NW STE 380
Practice Address - Street 2:
Practice Address - City:ATLANTA
Practice Address - State:GA
Practice Address - Zip Code:30309-2498
Practice Address - Country:US
Practice Address - Phone:770-270-5229
Practice Address - Fax:770-270-9323
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:PMR HOLDING COMPANY, LLC
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2020-08-10
Last Update Date:2020-08-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes174400000XOther Service ProvidersSpecialistGroup - Multi-Specialty
No208D00000XAllopathic & Osteopathic PhysiciansGeneral PracticeGroup - Multi-Specialty