Basic Information
| Provider Information | |||||||||
| NPI: | 1912069022 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | CU CHIAM | ||||||||
| FirstName: | ALAN | ||||||||
| MiddleName: | KEH | ||||||||
| NamePrefix: | DR. | ||||||||
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| Credential: | M.D. | ||||||||
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| Mailing Information | |||||||||
| Address1: | 10051 5TH STREET N. | ||||||||
| Address2: | SUITE 200 | ||||||||
| City: | ST. PETERSBURG | ||||||||
| State: | FL | ||||||||
| PostalCode: | 337022211 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7278282370 | ||||||||
| FaxNumber: | 4047550520 | ||||||||
| Practice Location | |||||||||
| Address1: | 1188 RALPH DAVID ABERNATHY BLVD. | ||||||||
| Address2: | |||||||||
| City: | ATLANTA | ||||||||
| State: | GA | ||||||||
| PostalCode: | 30310 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4047558996 | ||||||||
| FaxNumber: | 4047550520 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 12/14/2006 | ||||||||
| LastUpdateDate: | 12/14/2016 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207R00000X | 042554 | GA | Y | Allopathic & Osteopathic Physicians | Internal Medicine |
ID Information
| ID | Type | State | Issuer | Description | 000718913D | 05 | GA | MEDICAID |