Provider Demographics
NPI:1134126683
Name:TAN, ANNIE R (MD)
Entity Type:Individual
Prefix:
First Name:ANNIE
Middle Name:R
Last Name:TAN
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 1:33100 CLEVELAND CLINIC BLVD
Mailing Address - Street 2:
Mailing Address - City:AVON
Mailing Address - State:OH
Mailing Address - Zip Code:44011-1390
Mailing Address - Country:US
Mailing Address - Phone:440-695-4000
Mailing Address - Fax:
Practice Address - Street 1:33100 CLEVELAND CLINIC BLVD
Practice Address - Street 2:
Practice Address - City:AVON
Practice Address - State:OH
Practice Address - Zip Code:44011-1390
Practice Address - Country:US
Practice Address - Phone:440-695-4000
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2005-06-30
Last Update Date:2018-02-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH35.091239207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
AL000021769Medicaid
AL000021769Medicaid
AL000021769Medicare ID - Type Unspecified