1982702635 NPI number — DR. THANH-HA PHAM MD

Table of content: DR. THANH-HA PHAM MD (NPI 1982702635)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1982702635 NPI number — DR. THANH-HA PHAM MD

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
PHAM
Provider First Name:
THANH-HA
Provider Middle Name:
Provider Name Prefix Text:
DR.
Provider Name Suffix Text:
Provider Credential Text:
MD
Provider Gender Code:
F

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1982702635
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
12/29/2009
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
1510 N 28TH ST
Provider Second Line Business Mailing Address:
SUITE 308
Provider Business Mailing Address City Name:
RICHMOND
Provider Business Mailing Address State Name:
VA
Provider Business Mailing Address Postal Code:
23223-5311
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
804-644-1665
Provider Business Mailing Address Fax Number:
804-644-5285

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
1510 N 28TH ST
Provider Second Line Business Practice Location Address:
SUITE 308
Provider Business Practice Location Address City Name:
RICHMOND
Provider Business Practice Location Address State Name:
VA
Provider Business Practice Location Address Postal Code:
23223-5311
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
804-644-1665
Provider Business Practice Location Address Fax Number:
804-644-5285
Provider Enumeration Date:
09/20/2006

Additional Information

Authorized Official

Authorized Official Last Name:
Authorized Official First Name:
Authorized Official Middle Name:
Authorized Official Title or Position:
Authorized Official Telephone Number:

Provider Taxonomy Codes

  • Taxonomy code: 207R00000X , with the licence number:  22163 , registered in the state of WV ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 207R00000X , with the licence number: 0101244710 , registered in the state of VA ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)

  • Identifier: 001788654 . This is a "BLUE CROSS BLUE SHIELD" identifier , issued by the state of ( WV ) . This identifiers is of the category "OTHER".
  • Identifier: 3810004094 , issued by the state of ( WV ) . This identifiers is of the category "MEDICAID".
  • Identifier: C06695 . This is a "GROUP PTAN" identifier , issued by the state of ( VA ) . This identifiers is of the category "OTHER".




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