Provider Demographics
NPI:1538188057
Name:PHAM, THONG QUOC (MD)
Entity type:Individual
Prefix:
First Name:THONG
Middle Name:QUOC
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:PO BOX 3128
Mailing Address - Street 2:
Mailing Address - City:SIOUX CITY
Mailing Address - State:IA
Mailing Address - Zip Code:51102-3128
Mailing Address - Country:US
Mailing Address - Phone:712-239-4702
Mailing Address - Fax:712-224-5898
Practice Address - Street 1:5885 SUNNYBROOK DR
Practice Address - Street 2:SUITE L-200
Practice Address - City:SIOUX CITY
Practice Address - State:IA
Practice Address - Zip Code:51106-4203
Practice Address - Country:US
Practice Address - Phone:712-239-4702
Practice Address - Fax:712-224-5898
Is Sole Proprietor?:No
Enumeration Date:2006-07-18
Last Update Date:2015-10-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IAMD-37909207RC0001X
NE24761207RC0001X
IL36077772207RC0000X, 207RC0001X, 2085B0100X, 2085U0001X
SD7294207RC0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RC0001XAllopathic & Osteopathic PhysiciansInternal MedicineClinical Cardiac Electrophysiology
No207RC0000XAllopathic & Osteopathic PhysiciansInternal MedicineCardiovascular Disease
No2085B0100XAllopathic & Osteopathic PhysiciansRadiologyBody Imaging
No2085U0001XAllopathic & Osteopathic PhysiciansRadiologyDiagnostic Ultrasound
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL036077772 1Medicaid
IL101 15504OtherB/C B/S OF ILLINOIS
IA1538188057Medicaid
GACB0709/060028732OtherRR MEDICARE GROUP #/PIN
IL36-2772589OtherEIN
GACB0709/060028732OtherRR MEDICARE GROUP #/PIN
ILE18873Medicare UPIN
IL036077772 1Medicaid