Provider Demographics
NPI:1225020647
Name:TAN TAN, MELY (MD)
Entity Type:Individual
Prefix:
First Name:MELY
Middle Name:
Last Name:TAN 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:PO BOX 664056
Mailing Address - Street 2:
Mailing Address - City:MUNSTER
Mailing Address - State:IN
Mailing Address - Zip Code:46321-1758
Mailing Address - Country:US
Mailing Address - Phone:317-528-4800
Mailing Address - Fax:317-865-1479
Practice Address - Street 1:8242 CALUMET AVE
Practice Address - Street 2:
Practice Address - City:MUNSTER
Practice Address - State:IN
Practice Address - Zip Code:46321-1758
Practice Address - Country:US
Practice Address - Phone:219-836-5738
Practice Address - Fax:219-836-5782
Is Sole Proprietor?:No
Enumeration Date:2005-08-22
Last Update Date:2013-11-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN01031700A2080N0001X, 208000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208000000XAllopathic & Osteopathic PhysiciansPediatrics
No2080N0001XAllopathic & Osteopathic PhysiciansPediatricsNeonatal-Perinatal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL0090000854OtherBCBS GROUP NUMBER
IN100462470Medicaid
IN140220SSMedicare PIN
H25880Medicare UPIN