Provider Demographics
NPI:1336148055
Name:PHANG, ROBERT SOO-MIN (MD)
Entity Type:Individual
Prefix:
First Name:ROBERT
Middle Name:SOO-MIN
Last Name:PHANG
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:PO BOX 14890
Mailing Address - Street 2:ST. PETER'S HEALTH PARTNERS PAYER CREDENTIALING
Mailing Address - City:ALBANY
Mailing Address - State:NY
Mailing Address - Zip Code:12212-4890
Mailing Address - Country:US
Mailing Address - Phone:518-458-2000
Mailing Address - Fax:518-458-1524
Practice Address - Street 1:2 PALISADES DR
Practice Address - Street 2:
Practice Address - City:ALBANY
Practice Address - State:NY
Practice Address - Zip Code:12205-1438
Practice Address - Country:US
Practice Address - Phone:518-458-2000
Practice Address - Fax:518-458-1524
Is Sole Proprietor?:No
Enumeration Date:2005-07-14
Last Update Date:2021-06-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY235501207RC0000X, 207RC0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RC0001XAllopathic & Osteopathic PhysiciansInternal MedicineClinical Cardiac Electrophysiology
No207RC0000XAllopathic & Osteopathic PhysiciansInternal MedicineCardiovascular Disease
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY02636657Medicaid
VT1017514Medicaid
NY625Q63Medicare PIN
NYRA5996Medicare PIN
VT1017514Medicaid