Provider Demographics
NPI:1275566846
Name:PHAN, PHONG THANH (MD)
Entity Type:Individual
Prefix:
First Name:PHONG
Middle Name:THANH
Last Name:PHAN
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1 INDEPENDENCE PT STE 212
Mailing Address - Street 2:
Mailing Address - City:GREENVILLE
Mailing Address - State:SC
Mailing Address - Zip Code:29615-4536
Mailing Address - Country:US
Mailing Address - Phone:864-797-6328
Mailing Address - Fax:
Practice Address - Street 1:200 FLEETWOOD DR
Practice Address - Street 2:
Practice Address - City:EASLEY
Practice Address - State:SC
Practice Address - Zip Code:29640-2022
Practice Address - Country:US
Practice Address - Phone:864-442-7200
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-07-08
Last Update Date:2019-05-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC2006-00994207R00000X
SCMD29289207R00000X
SC29289208M00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208M00000XAllopathic & Osteopathic PhysiciansHospitalist
No207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
NC5904304Medicaid
SCN94006Medicaid
SCAA24645019Medicare PIN
SCAA24649068Medicare PIN
NCI64526Medicare UPIN
SCN94006Medicaid