Provider Demographics
NPI:1609436427
Name:CORCORAN, TARA FUNK (MD)
Entity Type:Individual
Prefix:
First Name:TARA
Middle Name:FUNK
Last Name:CORCORAN
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:225 EAST CHICAGO AVE
Mailing Address - Street 2:BOX 62
Mailing Address - City:CHICAGO
Mailing Address - State:IL
Mailing Address - Zip Code:60611
Mailing Address - Country:US
Mailing Address - Phone:312-227-6082
Mailing Address - Fax:
Practice Address - Street 1:225 E CHICAGO AVE 2ND FLOOR
Practice Address - Street 2:
Practice Address - City:CHICAGO
Practice Address - State:IL
Practice Address - Zip Code:60611
Practice Address - Country:US
Practice Address - Phone:312-227-6082
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2019-06-14
Last Update Date:2023-06-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI4351045070208000000X
IL036.159978207PP0204X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207PP0204XAllopathic & Osteopathic PhysiciansEmergency MedicinePediatric Emergency Medicine
No208000000XAllopathic & Osteopathic PhysiciansPediatrics
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI4351045070OtherLIMITED EDUC LICENSES
MI5315207175MIOtherCONTROLLED SUBSTANCE LICENSES