Healthcare Provider Details

I. General information

NPI: 1790741593
Provider Name (Legal Business Name): EMMELEEN F PHAN MD
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 04/21/2006
Last Update Date: 12/30/2014
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1000 MEDICAL CENTER BLVD
LAWRENCEVILLE GA
30046-7694
US

IV. Provider business mailing address

1000 MEDICAL CENTER BLVD
LAWRENCEVILLE GA
30046-7694
US

V. Phone/Fax

Practice location:
  • Phone: 678-312-3317
  • Fax: 678-312-4416
Mailing address:
  • Phone: 678-312-3317
  • Fax: 678-312-4416

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code208000000X
TaxonomyPediatrics Physician
License Number054423
License Number StateGA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: