Provider Demographics
NPI:1578755898
Name:RICHARD PHAM MD PA
Entity Type:Organization
Organization Name:RICHARD PHAM MD PA
Other - Org Name:FAMILY HEALTH & WELLNESS CENTER
Other - Org Type:Doing Business As
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:RICHARD
Authorized Official - Middle Name:D
Authorized Official - Last Name:PHAM
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:409-381-5750
Mailing Address - Street 1:492 SPRINGHILL ST
Mailing Address - Street 2:SUITE A
Mailing Address - City:JASPER
Mailing Address - State:TX
Mailing Address - Zip Code:75951-4922
Mailing Address - Country:US
Mailing Address - Phone:409-381-5750
Mailing Address - Fax:409-384-2018
Practice Address - Street 1:492 SPRINGHILL ST
Practice Address - Street 2:SUITE A
Practice Address - City:JASPER
Practice Address - State:TX
Practice Address - Zip Code:75951-4922
Practice Address - Country:US
Practice Address - Phone:409-381-5750
Practice Address - Fax:409-384-2018
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-08-10
Last Update Date:2016-06-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXK2098207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX187770601Medicaid
TX187770601Medicaid
TX00Y101Medicare PIN