Healthcare Provider Details

I. General information

NPI: 1194869842
Provider Name (Legal Business Name): HOANGMAI THI PHAN M.D
Entity Type: Individual
Gender: Female
Sole Proprietor: N

Provider Other Name: MAI THI PHAN MD

II. Dates (important events)

Enumeration Date: 02/16/2007
Last Update Date: 08/21/2008
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

150 E HURON ST SUITE 1226
CHICAGO IL
60611-2999
US

IV. Provider business mailing address

150 E HURON ST SUITE 1226
CHICAGO IL
60611-2999
US

V. Phone/Fax

Practice location:
  • Phone: 312-951-0501
  • Fax: 312-951-0970
Mailing address:
  • Phone: 312-951-0501
  • Fax: 312-951-0970

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207R00000X
TaxonomyInternal Medicine Physician
License Number036072515
License Number StateIL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: