Provider Demographics
NPI:1780690503
Name:PHAM, HIEP
Entity Type:Individual
Prefix:
First Name:HIEP
Middle Name:
Last Name:PHAM
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5730 EXECUTIVE DR STE 230
Mailing Address - Street 2:
Mailing Address - City:CATONSVILLE
Mailing Address - State:MD
Mailing Address - Zip Code:21228-1762
Mailing Address - Country:US
Mailing Address - Phone:410-402-2379
Mailing Address - Fax:410-469-3085
Practice Address - Street 1:2030 WINDSOR RUN LN
Practice Address - Street 2:
Practice Address - City:MATTHEWS
Practice Address - State:NC
Practice Address - Zip Code:28105-0054
Practice Address - Country:US
Practice Address - Phone:704-443-6250
Practice Address - Fax:704-443-6279
Is Sole Proprietor?:No
Enumeration Date:2006-08-01
Last Update Date:2022-04-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SC22778207QG0300X
NC9601434207QG0300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207QG0300XAllopathic & Osteopathic PhysiciansFamily MedicineGeriatric Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
NC8967431Medicaid
SCN01439Medicaid
SCN01439Medicaid
SCSC44505019Medicare PIN
NC8967431Medicaid
SCSC44503365Medicare PIN
NCE21576Medicare UPIN