Provider Demographics
NPI:1174550172
Name:PHUNG, SON H (MD)
Entity type:Individual
Prefix:DR
First Name:SON
Middle Name:H
Last Name:PHUNG
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 1:400 MEDICAL PARK DR
Mailing Address - Street 2:
Mailing Address - City:WATERVLIET
Mailing Address - State:MI
Mailing Address - Zip Code:49098-9225
Mailing Address - Country:US
Mailing Address - Phone:269-463-3600
Mailing Address - Fax:
Practice Address - Street 1:725 MASON ST
Practice Address - Street 2:
Practice Address - City:FLINT
Practice Address - State:MI
Practice Address - Zip Code:48503-2421
Practice Address - Country:US
Practice Address - Phone:810-496-5543
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-06-26
Last Update Date:2023-03-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI4301079180207R00000X
IN01071370A208M00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
No208M00000XAllopathic & Osteopathic PhysiciansHospitalist
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI1101103412OtherBLUE CROSS PIN
MI110231493OtherRAILROAD MEDICARE
MI1538397120OtherGROUP NPI
MI4837343Medicaid
MIBP7605011OtherDEA
MI4837343Medicaid
H53240Medicare UPIN
H53240Medicare UPIN