Provider Demographics
NPI:1073598827
Name:TANKANOW, LARRY B (MD)
Entity Type:Individual
Prefix:
First Name:LARRY
Middle Name:B
Last Name:TANKANOW
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
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Other - Credentials:
Mailing Address - Street 1:27472 SCHOENHERR RD STE 100
Mailing Address - Street 2:
Mailing Address - City:WARREN
Mailing Address - State:MI
Mailing Address - Zip Code:48088-6675
Mailing Address - Country:US
Mailing Address - Phone:586-751-8844
Mailing Address - Fax:586-751-8596
Practice Address - Street 1:27472 SCHOENHERR RD STE 100
Practice Address - Street 2:
Practice Address - City:WARREN
Practice Address - State:MI
Practice Address - Zip Code:48088-6675
Practice Address - Country:US
Practice Address - Phone:586-751-8844
Practice Address - Fax:586-751-8596
Is Sole Proprietor?:No
Enumeration Date:2005-12-14
Last Update Date:2022-05-16
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
MI4301045330207RP1001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RP1001XAllopathic & Osteopathic PhysiciansInternal MedicinePulmonary Disease
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI4559970Medicaid
MI4559970Medicaid
MIN81840002Medicare ID - Type Unspecified
MIA77255Medicare UPIN