Provider Demographics
NPI:1033351440
Name:CHAN, MIRIAM R (MD)
Entity Type:Individual
Prefix:
First Name:MIRIAM
Middle Name:R
Last Name:CHAN
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:8994 PROVINCE ST
Mailing Address - Street 2:
Mailing Address - City:SARASOTA
Mailing Address - State:FL
Mailing Address - Zip Code:34240-8311
Mailing Address - Country:US
Mailing Address - Phone:407-319-5000
Mailing Address - Fax:
Practice Address - Street 1:10080 BALAYE RUN DR
Practice Address - Street 2:
Practice Address - City:TAMPA
Practice Address - State:FL
Practice Address - Zip Code:33619-7902
Practice Address - Country:US
Practice Address - Phone:813-490-6100
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2009-03-31
Last Update Date:2018-03-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLME115766207L00000X, 207LP3000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207LP3000XAllopathic & Osteopathic PhysiciansAnesthesiologyPediatric Anesthesiology
No207L00000XAllopathic & Osteopathic PhysiciansAnesthesiology
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL010603200Medicaid