Healthcare Provider Details

I. General information

NPI: 1649389891
Provider Name (Legal Business Name): KIET VI THAI, PC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 08/30/2006
Last Update Date: 08/22/2020
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

643 WASHINGTON AVE
PHILADELPHIA PA
19147-4825
US

IV. Provider business mailing address

643 WASHINGTON AVE
PHILADELPHIA PA
19147-4825
US

V. Phone/Fax

Practice location:
  • Phone: 215-462-1290
  • Fax: 215-462-1105
Mailing address:
  • Phone: 215-462-1290
  • Fax: 215-462-1105

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code208000000X
TaxonomyPediatrics Physician
License NumberMD-040810-L
License Number StatePA

VIII. Authorized Official

Name: DR. KIET VI THAI
Title or Position: PRESIDENT
Credential: M.D.
Phone: 215-462-1290