Provider Demographics
NPI:1083868608
Name:TAG, STEPHEN R (DC)
Entity Type:Individual
Prefix:DR
First Name:STEPHEN
Middle Name:R
Last Name:TAG
Suffix:
Gender:M
Credentials:DC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 864
Mailing Address - Street 2:
Mailing Address - City:BREWSTER
Mailing Address - State:MA
Mailing Address - Zip Code:02631-0864
Mailing Address - Country:US
Mailing Address - Phone:508-896-1811
Mailing Address - Fax:
Practice Address - Street 1:1573 MAIN ST
Practice Address - Street 2:
Practice Address - City:BREWSTER
Practice Address - State:MA
Practice Address - Zip Code:02631-1719
Practice Address - Country:US
Practice Address - Phone:508-896-1811
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2008-11-10
Last Update Date:2008-11-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MA1549111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes111N00000XChiropractic ProvidersChiropractor
Provider Identifiers
StateIdentifier IDID TypeIssuer
MAY36075OtherBCBS
U01281Medicare UPIN
MAU01281Medicare UPIN