Provider Demographics
NPI:1194869842
Name:PHAN, HOANGMAI THI (MD)
Entity type:Individual
Prefix:DR
First Name:HOANGMAI
Middle Name:THI
Last Name:PHAN
Suffix:
Gender:F
Credentials:MD
Other - Prefix:DR
Other - First Name:MAI
Other - Middle Name:THI
Other - Last Name:PHAN
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:MD
Mailing Address - Street 1:150 E HURON ST
Mailing Address - Street 2:SUITE 1226
Mailing Address - City:CHICAGO
Mailing Address - State:IL
Mailing Address - Zip Code:60611-2999
Mailing Address - Country:US
Mailing Address - Phone:312-951-0501
Mailing Address - Fax:312-951-0970
Practice Address - Street 1:150 E HURON ST
Practice Address - Street 2:SUITE 1226
Practice Address - City:CHICAGO
Practice Address - State:IL
Practice Address - Zip Code:60611-2999
Practice Address - Country:US
Practice Address - Phone:312-951-0501
Practice Address - Fax:312-951-0970
Is Sole Proprietor?:No
Enumeration Date:2007-02-16
Last Update Date:2008-08-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL036072515207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
L20544Medicare UPIN
D16609Medicare UPIN