MEDICARE: DR. TRUC THANH PHAM M.D.

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	207Q00000X	Family Medicine Physician	049706	GA

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program
2	52070574-001	OTHER	GA	BLUE CROSS BLUE SHIELD ID
3	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program

General Provider Information

NPI Number	:	1003808312
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	DR. TRUC THANH PHAM M.D.

Provider Business Mailing Address
First Line	:	3985 STEVE REYNOLDS BLVD
Second Line	:	SUITE K 102
City	:	NORCROSS
State	:	GA
Zip	:	30093-3035
Country	:	US
Telephone Number	:	678-367-0390
Fax Number	:	678-245-3391

Provider Business Practice Location Address
First Line	:	3985 STEVE REYNOLDS BLVD
Second Line	:	SUITE K 102
City	:	NORCROSS
State	:	GA
Zip	:	30093-3035
Country	:	US
Telephone Number	:	678-367-0390
Fax Number	:	678-245-3391

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	08/22/2005
Last Update Date	:	05/16/2008

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Directions to “ DR. TRUC THANH PHAM M.D.” Practice Location

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