Basic Information
| Provider Information | |||||||||
| NPI: | 1942399548 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | PHAN | ||||||||
| FirstName: | PHILLIP | ||||||||
| MiddleName: | C. | ||||||||
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| Credential: | M.D. | ||||||||
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| Mailing Information | |||||||||
| Address1: | 5445 LA BRANCH ST STE 100 | ||||||||
| Address2: | |||||||||
| City: | HOUSTON | ||||||||
| State: | TX | ||||||||
| PostalCode: | 770046835 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7139737246 | ||||||||
| FaxNumber: | 8325531337 | ||||||||
| Practice Location | |||||||||
| Address1: | 5445 LA BRANCH ST STE 100 | ||||||||
| Address2: | |||||||||
| City: | HOUSTON | ||||||||
| State: | TX | ||||||||
| PostalCode: | 770046835 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7139737246 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 10/12/2006 | ||||||||
| LastUpdateDate: | 07/21/2022 | ||||||||
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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 | 208VP0000X | N2242 | TX | N | Allopathic & Osteopathic Physicians | Pain Medicine | Pain Medicine | 208VP0014X | N2242 | TX | N | Allopathic & Osteopathic Physicians | Pain Medicine | Interventional Pain Medicine | 207LP2900X | N2242 | TX | Y | Allopathic & Osteopathic Physicians | Anesthesiology | Pain Medicine |
ID Information
| ID | Type | State | Issuer | Description | 179470307 | 05 | TX | MEDICAID |