Healthcare Provider Details

I. General information

NPI: 1053015164
Provider Name (Legal Business Name): ALICE PHUONG QUYNH PHAM MD
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 03/30/2023
Last Update Date: 04/17/2026
Certification Date: 04/17/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1 MEDICAL CENTER BLVD
WINSTON SALEM NC
27157-0001
US

IV. Provider business mailing address

169 ASHLEY AVE
CHARLESTON SC
29425-8905
US

V. Phone/Fax

Practice location:
  • Phone: 336-716-2694
  • Fax:
Mailing address:
  • Phone: 901-827-9818
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code208000000X
TaxonomyPediatrics Physician
License NumberRTL23-0405
License Number StateNC

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: