Provider Demographics
NPI:1518025410
Name:SHAN, TAI CHI (MD)
Entity Type:Individual
Prefix:DR
First Name:TAI CHI
Middle Name:
Last Name:SHAN
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 1:2201 EAST JEFFERSON STREET
Mailing Address - Street 2:PPQA MEDICARE COMPLIANCE UNIT 6
Mailing Address - City:ROCKVILLE
Mailing Address - State:MD
Mailing Address - Zip Code:20852-4908
Mailing Address - Country:US
Mailing Address - Phone:301-816-6660
Mailing Address - Fax:301-816-6308
Practice Address - Street 1:501 NORTH FREDERICK AVENUE
Practice Address - Street 2:
Practice Address - City:GAITHERSBURG
Practice Address - State:MD
Practice Address - Zip Code:20877-2598
Practice Address - Country:US
Practice Address - Phone:301-258-7203
Practice Address - Fax:301-258-7294
Is Sole Proprietor?:No
Enumeration Date:2006-12-04
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MDD45187152WP0200X
VA0101042637152WP0200X
DCMD17409152WP0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152WP0200XEye and Vision Services ProvidersOptometristPediatrics
Provider Identifiers
StateIdentifier IDID TypeIssuer
546303M92Medicare ID - Type Unspecified
E22177Medicare UPIN