Provider Demographics
NPI:1457391039
Name:PHAN, BINH AN PHUONG (MD)
Entity Type:Individual
Prefix:
First Name:BINH AN
Middle Name:PHUONG
Last Name:PHAN
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 1:2160 S 1ST AVE
Mailing Address - Street 2:BLDG 110 RM 6221
Mailing Address - City:MAYWOOD
Mailing Address - State:IL
Mailing Address - Zip Code:60153-3328
Mailing Address - Country:US
Mailing Address - Phone:708-327-2784
Mailing Address - Fax:708-327-2771
Practice Address - Street 1:2160 S 1ST AVE
Practice Address - Street 2:BLDG 110 RM 6221
Practice Address - City:MAYWOOD
Practice Address - State:IL
Practice Address - Zip Code:60153-3328
Practice Address - Country:US
Practice Address - Phone:708-327-2784
Practice Address - Fax:708-327-2771
Is Sole Proprietor?:No
Enumeration Date:2006-06-08
Last Update Date:2012-09-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL036121748207RC0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RC0000XAllopathic & Osteopathic PhysiciansInternal MedicineCardiovascular Disease
Provider Identifiers
StateIdentifier IDID TypeIssuer
WA0198831OtherLIWA
WA8431439Medicaid
WABSWAOther3092PH
WABSWAOther3092PH
WAG8855272Medicare PIN
WAP00313338Medicare PIN