Provider Demographics
NPI:1255321998
Name:PHAN, MAI TRUC (MD)
Entity Type:Individual
Prefix:DR
First Name:MAI
Middle Name:TRUC
Last Name:PHAN
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
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Other - Credentials:
Mailing Address - Street 1:PO BOX 9142
Mailing Address - Street 2:MASS GENERAL PHYSICIAN ORGANIZATION
Mailing Address - City:CHARLESTOWN
Mailing Address - State:MA
Mailing Address - Zip Code:02129-9142
Mailing Address - Country:US
Mailing Address - Phone:617-267-7171
Mailing Address - Fax:617-262-2608
Practice Address - Street 1:388 COMMONWELATH AVE MBB
Practice Address - Street 2:MGH BACK BAY
Practice Address - City:BOSTON
Practice Address - State:MA
Practice Address - Zip Code:02215-2800
Practice Address - Country:US
Practice Address - Phone:617-267-7171
Practice Address - Fax:617-262-2608
Is Sole Proprietor?:No
Enumeration Date:2005-10-25
Last Update Date:2012-11-26
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
MA153182207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
MA3167488Medicaid
MAJ17866OtherBCBS MA
MA153182OtherTUFTS HEALTH PLAN
MA153182OtherTUFTS HEALTH PLAN
MAJ17866OtherBCBS MA