Healthcare Provider Details

I. General information

NPI: 1255321998
Provider Name (Legal Business Name): MAI TRUC PHAN MD
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 10/25/2005
Last Update Date: 11/26/2012
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

388 COMMONWELATH AVE MBB MGH BACK BAY
BOSTON MA
02215-2800
US

IV. Provider business mailing address

PO BOX 9142 MASS GENERAL PHYSICIAN ORGANIZATION
CHARLESTOWN MA
02129-9142
US

V. Phone/Fax

Practice location:
  • Phone: 617-267-7171
  • Fax: 617-262-2608
Mailing address:
  • Phone: 617-267-7171
  • Fax: 617-262-2608

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License Number153182
License Number StateMA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: