Individual
LOC B PHAM
Active
Sole proprietor
No
Provider details
NPI number
Gender
Man
Credential
MD
Contact information
Practice address
677 CHURCH ST NE, MARIETTA, GA 30060-1101
(770) 794-0477
(770) 794-3108
Mailing address
531 ROSELANE ST NW STE 830, MARIETTA, GA 30060-6979
(770) 794-0477
Taxonomy
Speciality
Code
Description
License number
State
207L00000X
Anesthesiology Physician
33976
TN
207L00000X
Anesthesiology Physician
Primary
81133
GA
207LP2900X
Pain Medicine (Anesthesiology) Physician
081133
GA
207LP3000X
Pediatric Anesthesiology Physician
081133
GA
208VP0000X
Pain Medicine Physician
081133
GA
208VP0014X
Interventional Pain Medicine Physician
081133
GA
Other
Other identifiers
Code
Description
Identifier
Issuer
State
01
—
050074254
MCRR
TN
01
—
100030563
PHP TENNCARE
TN
01
—
3146471
BLUECARE
TN
05
—
3851898
—
TN
Enumeration date
01/09/2006
Last updated
10/18/2023
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