Provider Demographics
NPI:1467482703
Name:TAM, KENNETH C (MD)
Entity Type:Individual
Prefix:DR
First Name:KENNETH
Middle Name:C
Last Name:TAM
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:217 GRAND ST FL 9
Mailing Address - Street 2:
Mailing Address - City:NEW YORK
Mailing Address - State:NY
Mailing Address - Zip Code:10013-4223
Mailing Address - Country:US
Mailing Address - Phone:212-233-8813
Mailing Address - Fax:212-267-3303
Practice Address - Street 1:217 GRAND ST FL 9
Practice Address - Street 2:
Practice Address - City:NEW YORK
Practice Address - State:NY
Practice Address - Zip Code:10013-4286
Practice Address - Country:US
Practice Address - Phone:212-233-8813
Practice Address - Fax:212-267-3303
Is Sole Proprietor?:No
Enumeration Date:2006-07-03
Last Update Date:2017-04-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY173277207R00000X, 207RC0000X, 2085N0904X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RC0000XAllopathic & Osteopathic PhysiciansInternal MedicineCardiovascular Disease
No207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
No2085N0904XAllopathic & Osteopathic PhysiciansRadiologyNuclear Radiology
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY997F66WR321OtherMEDICARE PIN (INDIVIDUAL)
NY03109868Medicaid
NY997F66WR321OtherMEDICARE PIN (INDIVIDUAL)
NYWWR321Medicare PIN