Provider Demographics
NPI:1063682219
Name:PHAN H THANH M D P C
Entity Type:Organization
Organization Name:PHAN H THANH M D P C
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:THANH
Authorized Official - Middle Name:HUU
Authorized Official - Last Name:PHAN
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:248-681-1025
Mailing Address - Street 1:4000 HIGHLAND RD
Mailing Address - Street 2:SUITE 110
Mailing Address - City:WATERFORD
Mailing Address - State:MI
Mailing Address - Zip Code:48328-2167
Mailing Address - Country:US
Mailing Address - Phone:248-681-1025
Mailing Address - Fax:248-681-1533
Practice Address - Street 1:4000 HIGHLAND RD
Practice Address - Street 2:SUITE 110
Practice Address - City:WATERFORD
Practice Address - State:MI
Practice Address - Zip Code:48328-2167
Practice Address - Country:US
Practice Address - Phone:248-681-1025
Practice Address - Fax:248-681-1533
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-03-04
Last Update Date:2008-04-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI4301 035554208600000X, 2086S0129X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes208600000XAllopathic & Osteopathic PhysiciansSurgeryGroup - Multi-Specialty
No2086S0129XAllopathic & Osteopathic PhysiciansSurgeryVascular SurgeryGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI0206316622OtherBCBSM/BCN
MI87199AOtherHAP
MI0631662Medicare PIN
MIA73809Medicare UPIN