Healthcare Provider Details

I. General information

NPI: 1275509937
Provider Name (Legal Business Name): BRIAN T NAM MD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 02/23/2006
Last Update Date: 12/17/2012
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4701 OGLETOWN STANTON ROAD SUITE 2100
NEWARK DE
19713
US

IV. Provider business mailing address

PO BOX 30170
WILMINGTON DE
19805-7170
US

V. Phone/Fax

Practice location:
  • Phone: 302-623-4530
  • Fax: 302-623-4578
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code208600000X
TaxonomySurgery Physician
License Number54904-20
License Number StateWI
# 2
Primary TaxonomyY
Taxonomy Code208G00000X
TaxonomyThoracic Surgery (Cardiothoracic Vascular Surgery) Physician
License NumberC1-0010222
License Number StateDE

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: