Provider Demographics
NPI:1972831337
Name:THEODORE S NAM MD PC
Entity type:Organization
Organization Name:THEODORE S NAM MD PC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PHYSICIAN
Authorized Official - Prefix:DR
Authorized Official - First Name:THEODORE
Authorized Official - Middle Name:S
Authorized Official - Last Name:NAM
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:610-383-4990
Mailing Address - Street 1:219 REECEVILLE ROAD
Mailing Address - Street 2:
Mailing Address - City:COATESVILLE
Mailing Address - State:PA
Mailing Address - Zip Code:19320-0000
Mailing Address - Country:US
Mailing Address - Phone:610-383-4990
Mailing Address - Fax:610-383-4989
Practice Address - Street 1:219 REECEVILLE ROAD
Practice Address - Street 2:
Practice Address - City:COATESVILLE
Practice Address - State:PA
Practice Address - Zip Code:19320-0000
Practice Address - Country:US
Practice Address - Phone:610-383-4990
Practice Address - Fax:610-383-4989
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2009-11-24
Last Update Date:2010-06-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PAMD4369262084P0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes2084P0800XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyPsychiatryGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
PA102398917Medicaid
PA102398917Medicaid