Healthcare Provider Details

I. General information

NPI: 1063682219
Provider Name (Legal Business Name): PHAN H THANH M D P C
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 03/04/2008
Last Update Date: 04/04/2008
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4000 HIGHLAND RD SUITE 110
WATERFORD MI
48328-2167
US

IV. Provider business mailing address

4000 HIGHLAND RD SUITE 110
WATERFORD MI
48328-2167
US

V. Phone/Fax

Practice location:
  • Phone: 248-681-1025
  • Fax: 248-681-1533
Mailing address:
  • Phone: 248-681-1025
  • Fax: 248-681-1533

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code208600000X
TaxonomySurgery Physician
License Number4301 035554
License Number StateMI
# 2
Primary TaxonomyN
Taxonomy Code2086S0129X
TaxonomyVascular Surgery Physician
License Number4301 035554
License Number StateMI

VIII. Authorized Official

Name: DR. THANH HUU PHAN
Title or Position: PRESIDENT
Credential: M.D.
Phone: 248-681-1025