Provider Demographics
NPI:1558457135
Name:TABE, CYRIL ETTA (MD)
Entity Type:Individual
Prefix:DR
First Name:CYRIL
Middle Name:ETTA
Last Name:TABE
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 1:250 N SHADELAND AVE
Mailing Address - Street 2:
Mailing Address - City:INDIANAPOLIS
Mailing Address - State:IN
Mailing Address - Zip Code:46219-4959
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:101 3RD AVE SW
Practice Address - Street 2:
Practice Address - City:MINOT
Practice Address - State:ND
Practice Address - Zip Code:58701-3880
Practice Address - Country:US
Practice Address - Phone:701-857-3655
Practice Address - Fax:701-857-3656
Is Sole Proprietor?:No
Enumeration Date:2006-10-04
Last Update Date:2023-01-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NMMD2009-0696208600000X, 208G00000X
ND10459208600000X, 208G00000X
IN01089362A208G00000X
NY282203208G00000X
CAC145282208G00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208G00000XAllopathic & Osteopathic PhysiciansThoracic Surgery (Cardiothoracic Vascular Surgery)
No208600000XAllopathic & Osteopathic PhysiciansSurgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
NM18307230Medicaid
ND14089Medicaid
ND165286Medicare UPIN
NM302874Medicare PIN