Provider Demographics
NPI:1194971374
Name:PHAM, KIEMANH (MD)
Entity type:Individual
Prefix:DR
First Name:KIEMANH
Middle Name:
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 1:6201 GREENLEIGH AVE
Mailing Address - Street 2:
Mailing Address - City:MIDDLE RIVER
Mailing Address - State:MD
Mailing Address - Zip Code:21220-2004
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:5801 SMITH AVE
Practice Address - Street 2:SUITE 3220
Practice Address - City:BALTIMORE
Practice Address - State:MD
Practice Address - Zip Code:21209-3652
Practice Address - Country:US
Practice Address - Phone:410-735-6403
Practice Address - Fax:410-735-6425
Is Sole Proprietor?:No
Enumeration Date:2008-08-07
Last Update Date:2021-12-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MDD69427207P00000X
CAA99032207P00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207P00000XAllopathic & Osteopathic PhysiciansEmergency Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
MD025242500Medicaid
MDD69427OtherMD LICENSE