Provider Demographics
NPI:1114915485
Name:HAI T PHAN
Entity Type:Organization
Organization Name:HAI T PHAN
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:HAI
Authorized Official - Middle Name:T
Authorized Official - Last Name:PHAN
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:909-883-9283
Mailing Address - Street 1:7223 CHURCH ST
Mailing Address - Street 2:SUITE A-20
Mailing Address - City:HIGHLAND
Mailing Address - State:CA
Mailing Address - Zip Code:92346-5869
Mailing Address - Country:US
Mailing Address - Phone:909-883-9283
Mailing Address - Fax:909-886-6704
Practice Address - Street 1:7223 CHURCH ST
Practice Address - Street 2:SUITE A-20
Practice Address - City:HIGHLAND
Practice Address - State:CA
Practice Address - Zip Code:92346-5869
Practice Address - Country:US
Practice Address - Phone:909-883-9283
Practice Address - Fax:909-886-6704
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2005-10-11
Last Update Date:2012-12-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207RN0300XAllopathic & Osteopathic PhysiciansInternal MedicineNephrologyGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAGR0092866Medicaid
CAGR0092866Medicaid