Provider Demographics
NPI:1326152851
Name:SIMON S TAN, MD PA
Entity Type:Organization
Organization Name:SIMON S TAN, MD PA
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:SIMON
Authorized Official - Middle Name:SY
Authorized Official - Last Name:TAN
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:817-488-0100
Mailing Address - Street 1:3600 WILLIAM D TATE AVE
Mailing Address - Street 2:SUITE 200
Mailing Address - City:GRAPEVINE
Mailing Address - State:TX
Mailing Address - Zip Code:76051-8723
Mailing Address - Country:US
Mailing Address - Phone:817-488-0100
Mailing Address - Fax:817-488-4568
Practice Address - Street 1:731 E SOUTHLAKE BLVD STE 170
Practice Address - Street 2:
Practice Address - City:SOUTHLAKE
Practice Address - State:TX
Practice Address - Zip Code:76092-6382
Practice Address - Country:US
Practice Address - Phone:817-488-0100
Practice Address - Fax:817-488-4568
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-08-19
Last Update Date:2018-10-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXL20232084N0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes2084N0400XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyNeurologyGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX0001JAOtherBCBS
TX151996901Medicaid
TX00527TMedicare ID - Type Unspecified
TXH59879Medicare UPIN