Provider Demographics
NPI:1154480630
Name:TAN, SIDHARTHA (MD)
Entity Type:Individual
Prefix:
First Name:SIDHARTHA
Middle Name:
Last Name:TAN
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
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Other - Last Name:
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Other - Credentials:
Mailing Address - Street 1:4201 ST. ANTOINE - UHC 5D - #226
Mailing Address - Street 2:UNIVERSITY PEDIATRICIANS
Mailing Address - City:DETROIT
Mailing Address - State:MI
Mailing Address - Zip Code:48201-2153
Mailing Address - Country:US
Mailing Address - Phone:313-745-4405
Mailing Address - Fax:313-966-0665
Practice Address - Street 1:3901 BEAUBIEN
Practice Address - Street 2:CHILDREN'S HOSPITAL OF MI
Practice Address - City:DETROIT
Practice Address - State:MI
Practice Address - Zip Code:48201
Practice Address - Country:US
Practice Address - Phone:313-745-4405
Practice Address - Fax:313-966-0665
Is Sole Proprietor?:No
Enumeration Date:2006-12-08
Last Update Date:2016-03-01
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
MI4301109000208000000X, 2080N0001X
IL0360688892080N0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2080N0001XAllopathic & Osteopathic PhysiciansPediatricsNeonatal-Perinatal Medicine
No208000000XAllopathic & Osteopathic PhysiciansPediatrics
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL036068889OtherSTATE LICENSE
MI4301109000OtherSTATE LICENSE