Provider Demographics
NPI:1417110206
Name:JASON C TANI MD PC
Entity Type:Organization
Organization Name:JASON C TANI MD PC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:MD
Authorized Official - Prefix:
Authorized Official - First Name:JASON
Authorized Official - Middle Name:C
Authorized Official - Last Name:TANI
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:480-635-1141
Mailing Address - Street 1:4540 E BASELINE RD
Mailing Address - Street 2:#119
Mailing Address - City:MESA
Mailing Address - State:AZ
Mailing Address - Zip Code:85206-4617
Mailing Address - Country:US
Mailing Address - Phone:480-635-1141
Mailing Address - Fax:480-635-1181
Practice Address - Street 1:4540 E BASELINE RD
Practice Address - Street 2:# 119
Practice Address - City:MESA
Practice Address - State:AZ
Practice Address - Zip Code:85206-4617
Practice Address - Country:US
Practice Address - Phone:480-635-1141
Practice Address - Fax:480-635-1181
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-07-02
Last Update Date:2008-07-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZ24700174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes174400000XOther Service ProvidersSpecialistGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
AZ5338460001Medicare NSC