Provider Demographics
NPI:1386828861
Name:MARK TAN, M.D., P.C.
Entity Type:Organization
Organization Name:MARK TAN, M.D., P.C.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:MARK
Authorized Official - Middle Name:
Authorized Official - Last Name:TAN
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:631-724-8900
Mailing Address - Street 1:222 MIDDLE COUNTRY RD
Mailing Address - Street 2:SUITE # 312
Mailing Address - City:SMITHTOWN
Mailing Address - State:NY
Mailing Address - Zip Code:11787-2871
Mailing Address - Country:US
Mailing Address - Phone:631-821-5893
Mailing Address - Fax:631-724-8901
Practice Address - Street 1:222 MIDDLE COUNTRY RD
Practice Address - Street 2:SUITE # 312
Practice Address - City:SMITHTOWN
Practice Address - State:NY
Practice Address - Zip Code:11787
Practice Address - Country:US
Practice Address - Phone:631-821-5893
Practice Address - Fax:631-724-8901
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-12-20
Last Update Date:2008-01-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY165674174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes174400000XOther Service ProvidersSpecialistGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY00986705Medicaid
NYC58894Medicare UPIN
NYWES521Medicare PIN