Provider Demographics
NPI:1881674570
Name:PHAM, PHUONG-MAI
Entity Type:Individual
Prefix:
First Name:PHUONG-MAI
Middle Name:
Last Name:PHAM
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:12 HIGH ST
Mailing Address - Street 2:STE 400
Mailing Address - City:LEWISTON
Mailing Address - State:ME
Mailing Address - Zip Code:04240-7634
Mailing Address - Country:US
Mailing Address - Phone:207-795-5709
Mailing Address - Fax:
Practice Address - Street 1:12 HIGH ST
Practice Address - Street 2:STE 400
Practice Address - City:LEWISTON
Practice Address - State:ME
Practice Address - Zip Code:04240-7634
Practice Address - Country:US
Practice Address - Phone:207-795-5709
Practice Address - Fax:
Is Sole Proprietor?:Not Answered
Enumeration Date:2006-01-19
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ME013801207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
MEMM5699Medicare ID - Type Unspecified
MEF40743Medicare UPIN