Basic Information
Provider Information | |||||||||
NPI: | 1396853511 | ||||||||
EntityType: | 1 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: |   | ||||||||
LastName: | PHAM | ||||||||
FirstName: | CHRISTINE | ||||||||
MiddleName: | T | ||||||||
NamePrefix: | DR. | ||||||||
NameSuffix: |   | ||||||||
Credential: | MD | ||||||||
OtherOrganizationName: |   | ||||||||
OtherOrganizationType: |   | ||||||||
OtherLastName: |   | ||||||||
OtherFirstName: |   | ||||||||
OtherMiddleName: |   | ||||||||
OtherNamePrefix: |   | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: |   | ||||||||
OtherLastNameType: |   | ||||||||
Mailing Information | |||||||||
Address1: | 660 S EUCLID AVE | ||||||||
Address2: | CB 8045 | ||||||||
City: | SAINT LOUIS | ||||||||
State: | MO | ||||||||
PostalCode: | 631101010 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 3143629043 | ||||||||
FaxNumber: | 3142861021 | ||||||||
Practice Location | |||||||||
Address1: | 4921 PARKVIEW PL | ||||||||
Address2: | DIV IM RHEUMATOLOGY, STE 5C | ||||||||
City: | SAINT LOUIS | ||||||||
State: | MO | ||||||||
PostalCode: | 631101032 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 3142862635 | ||||||||
FaxNumber: | 3142862338 | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 08/28/2006 | ||||||||
LastUpdateDate: | 11/12/2021 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: | F | ||||||||
AuthorizedOfficialLastName: |   | ||||||||
AuthorizedOfficialFirstName: |   | ||||||||
AuthorizedOfficialMiddleName: |   | ||||||||
AuthorizedOfficialTitleorPosition: |   | ||||||||
AuthorizedOfficialTelephone: |   | ||||||||
IsSoleProprietor: | N | ||||||||
IsOrganizationSubpart: |   | ||||||||
ParentOrganizationLBN: |   | ||||||||
AuthorizedOfficialNamePrefix: |   | ||||||||
AuthorizedOfficialNameSuffix: |   | ||||||||
AuthorizedOfficialCredential: |   | ||||||||
NPICertificationDate: |   |
Taxonomy Information
Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207RR0500X | R3J04 | MO | Y |   | Allopathic & Osteopathic Physicians | Internal Medicine | Rheumatology |
ID Information
ID | Type | State | Issuer | Description | 204762306 | 05 | MO |   | MEDICAID |