Provider Demographics
NPI:1972678530
Name:PHAM, CHUC V (MD)
Entity Type:Individual
Prefix:DR
First Name:CHUC
Middle Name:V
Last Name:PHAM
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1770 MAYNARDS MILL RD
Mailing Address - Street 2:
Mailing Address - City:FORSYTH
Mailing Address - State:GA
Mailing Address - Zip Code:31029
Mailing Address - Country:US
Mailing Address - Phone:478-335-7284
Mailing Address - Fax:
Practice Address - Street 1:400 CHARTER BLVD
Practice Address - Street 2:
Practice Address - City:MACON
Practice Address - State:GA
Practice Address - Zip Code:31210-4831
Practice Address - Country:US
Practice Address - Phone:478-757-6000
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-11-21
Last Update Date:2022-07-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA26916207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA00466947BMedicaid
GAD91044Medicare UPIN