Provider Demographics
NPI:1619214285
Name:FUNG, PHOENIX C (MD)
Entity Type:Individual
Prefix:DR
First Name:PHOENIX
Middle Name:C
Last Name:FUNG
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1307 FEDERAL ST STE B100
Mailing Address - Street 2:
Mailing Address - City:PITTSBURGH
Mailing Address - State:PA
Mailing Address - Zip Code:15212-4761
Mailing Address - Country:US
Mailing Address - Phone:412-359-8900
Mailing Address - Fax:412-359-8977
Practice Address - Street 1:1307 FEDERAL ST STE B100
Practice Address - Street 2:
Practice Address - City:PITTSBURGH
Practice Address - State:PA
Practice Address - Zip Code:15212
Practice Address - Country:US
Practice Address - Phone:412-359-8900
Practice Address - Fax:412-359-8977
Is Sole Proprietor?:Yes
Enumeration Date:2013-01-15
Last Update Date:2020-10-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PAMD460608207RG0100X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RG0100XAllopathic & Osteopathic PhysiciansInternal MedicineGastroenterology
Provider Identifiers
StateIdentifier IDID TypeIssuer
13773815OtherCAQH