Basic Information
| Provider Information | |||||||||
| NPI: | 1316042849 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | PHAM | ||||||||
| FirstName: | HAI | ||||||||
| MiddleName: | VAN | ||||||||
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| Credential: | MD | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 1239 | ||||||||
| Address2: | |||||||||
| City: | TROY | ||||||||
| State: | MI | ||||||||
| PostalCode: | 480991239 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2488246600 | ||||||||
| FaxNumber: | 2483241477 | ||||||||
| Practice Location | |||||||||
| Address1: | 4800 FREDERICKSBURG RD | ||||||||
| Address2: | STE 127 | ||||||||
| City: | SAN ANTONIO | ||||||||
| State: | TX | ||||||||
| PostalCode: | 782293628 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2107335072 | ||||||||
| FaxNumber: | 2107338649 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 09/13/2006 | ||||||||
| LastUpdateDate: | 09/04/2020 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 09/04/2020 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207Q00000X | J9781 | TX | N | Allopathic & Osteopathic Physicians | Family Medicine | 207QG0300X | J9781 | TX | N | Allopathic & Osteopathic Physicians | Family Medicine | Geriatric Medicine | 207R00000X | J9781 | TX | Y | Allopathic & Osteopathic Physicians | Internal Medicine |
ID Information
| ID | Type | State | Issuer | Description | 179041201 | 05 | TX | MEDICAID | 0002MU | 01 | TX | GROUP BCBS OF TX | OTHER | P00296211 | 01 | TX | RAIL ROAD MEDICARE | OTHER |