MEDICARE: DR. JACK M PHAM DNP, APRN, FNP-BC

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	363LF0000X	Family Nurse Practitioner	209027448	IL
2	363L00000X	Nurse Practitioner	209027448	IL
3	363LP2300X	Primary Care Nurse Practitioner	209027448	IL

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	2023019429	OTHER		ANCC
2	041460482	OTHER	IL	IDFPR NURSING BOARD

General Provider Information

NPI Number	:	1427566454
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	DR. JACK M PHAM DNP, APRN, FNP-BC

Provider Business Mailing Address
First Line	:	4947 N WINTHROP AVE
Second Line	:
City	:	CHICAGO
State	:	IL
Zip	:	60640-3607
Country	:	US
Telephone Number	:	773-455-4325
Fax Number	:	773-838-0902

Provider Business Practice Location Address
First Line	:	4947 N WINTHROP AVE
Second Line	:
City	:	CHICAGO
State	:	IL
Zip	:	60640-3607
Country	:	US
Telephone Number	:	773-455-4325
Fax Number	:	773-838-0902

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

Provider Enumeration Date	:	01/11/2018
Last Update Date	:	03/05/2024

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