Provider Demographics
NPI:1073583316
Name:TATARCHUK, TERRENCE WAYNE (MD)
Entity Type:Individual
Prefix:
First Name:TERRENCE
Middle Name:WAYNE
Last Name:TATARCHUK
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
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Other - Credentials:
Mailing Address - Street 1:8795 PINE RIDGE DR
Mailing Address - Street 2:SUITE B
Mailing Address - City:CADILLAC
Mailing Address - State:MI
Mailing Address - Zip Code:49601-9777
Mailing Address - Country:US
Mailing Address - Phone:231-775-1306
Mailing Address - Fax:231-775-9701
Practice Address - Street 1:8795 PINE RIDGE DR
Practice Address - Street 2:SUITE B
Practice Address - City:CADILLAC
Practice Address - State:MI
Practice Address - Zip Code:49601-9777
Practice Address - Country:US
Practice Address - Phone:231-775-1306
Practice Address - Fax:231-775-9701
Is Sole Proprietor?:Yes
Enumeration Date:2006-01-26
Last Update Date:2010-02-23
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
MI4301039879208600000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208600000XAllopathic & Osteopathic PhysiciansSurgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI01279OtherPRIORITY HEALTH
MI209380410Medicaid
MI103633OtherPREFERRED CHOICES
MIP26654FOtherBLUE CARE NETWORK
MI0208309261OtherBLUE CROSS BLUE SHIELD
MIM009095OtherTRICARE
MI01279OtherPRIORITY HEALTH
MI0M88610Medicare ID - Type Unspecified
MIP26654FOtherBLUE CARE NETWORK