Healthcare Provider Details

I. General information

NPI: 1043261456
Provider Name (Legal Business Name): NHAN THANH PHAM D.O
Entity Type: Individual
Gender: Male
Sole Proprietor: X

II. Dates (important events)

Enumeration Date: 05/12/2006
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

555 S OLD WOODWARD AVE STE 1309
BIRMINGHAM MI
48009-6658
US

IV. Provider business mailing address

555 S OLD WOODWARD AVE STE 1309
BIRMINGHAM MI
48009-6658
US

V. Phone/Fax

Practice location:
  • Phone: 248-930-6581
  • Fax:
Mailing address:
  • Phone: 248-930-6581
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code208200000X
TaxonomyPlastic Surgery Physician
License Number5101015887
License Number StateMI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: