Provider Demographics
NPI:1649569146
Name:MINH VAN PHAM MD INC PS
Entity Type:Organization
Organization Name:MINH VAN PHAM MD INC PS
Other - Org Name:MINH VAN PHAM
Other - Org Type:Former Legal Business Name
Authorized Official - Title/Position:GENERAL PRACTICE MD
Authorized Official - Prefix:DR
Authorized Official - First Name:MINH
Authorized Official - Middle Name:VAN
Authorized Official - Last Name:PHAM
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:206-722-6268
Mailing Address - Street 1:5401 RAINIER AVE S
Mailing Address - Street 2:
Mailing Address - City:SEATTLE
Mailing Address - State:WA
Mailing Address - Zip Code:98118-2438
Mailing Address - Country:US
Mailing Address - Phone:206-722-6268
Mailing Address - Fax:206-725-5435
Practice Address - Street 1:5401 RAINIER AVE S
Practice Address - Street 2:
Practice Address - City:SEATTLE
Practice Address - State:WA
Practice Address - Zip Code:98118-2438
Practice Address - Country:US
Practice Address - Phone:206-722-6268
Practice Address - Fax:206-725-5435
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2011-04-05
Last Update Date:2014-07-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WA0021481261QP2300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QP2300XAmbulatory Health Care FacilitiesClinic/CenterPrimary Care
Provider Identifiers
StateIdentifier IDID TypeIssuer
WA1038181Medicaid
WA0104155Medicare PIN
WAA-55128Medicare UPIN