Healthcare Provider Details

I. General information

NPI: 1114260122
Provider Name (Legal Business Name): TAM PHAM MCLEAN
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 03/28/2013
Last Update Date: 03/03/2021
Certification Date: 03/03/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

5105 SOM CENTER RD #106
WILLOUGHBY OH
44094-4203
US

IV. Provider business mailing address

7590 AUBURN ROAD, SUITE 014 ATTN: MED STAFF
CONCORD TWP OH
44077-9176
US

V. Phone/Fax

Practice location:
  • Phone: 440-953-5740
  • Fax: 440-953-5741
Mailing address:
  • Phone: 440-354-1899
  • Fax: 440-354-1845

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License Number35.127316
License Number StateOH

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: