Basic Information
| Provider Information | |||||||||
| NPI: | 1053817205 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | PHAM | ||||||||
| FirstName: | NAM | ||||||||
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| Credential: | DO | ||||||||
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| Mailing Information | |||||||||
| Address1: | 5501 OLD YORK RD STE 1 | ||||||||
| Address2: | |||||||||
| City: | PHILADELPHIA | ||||||||
| State: | PA | ||||||||
| PostalCode: | 191413098 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2154564555 | ||||||||
| FaxNumber: | 2154551933 | ||||||||
| Practice Location | |||||||||
| Address1: | 5501 OLD YORK RD STE 1 | ||||||||
| Address2: | |||||||||
| City: | PHILADELPHIA | ||||||||
| State: | PA | ||||||||
| PostalCode: | 191413098 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2154564555 | ||||||||
| FaxNumber: | 2154551933 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 04/04/2018 | ||||||||
| LastUpdateDate: | 06/20/2022 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 06/20/2022 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207R00000X | OT018441 | PA | N | Allopathic & Osteopathic Physicians | Internal Medicine | 207R00000X | OS021735 | PA | N | Allopathic & Osteopathic Physicians | Internal Medicine | 207RI0200X | OT018441 | PA | Y | Allopathic & Osteopathic Physicians | Internal Medicine | Infectious Disease |
No ID Information.