Provider Demographics
NPI:1619237625
Name:TADGE KANJO GENERAL SURGERY LLC
Entity Type:Organization
Organization Name:TADGE KANJO GENERAL SURGERY LLC
Other - Org Name:ATOMIC CITY SURGERY
Other - Org Type:Doing Business As
Authorized Official - Title/Position:SOLE MBR
Authorized Official - Prefix:
Authorized Official - First Name:TADGE
Authorized Official - Middle Name:
Authorized Official - Last Name:KANJO
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:505-246-6910
Mailing Address - Street 1:196 ARROWHEAD DR
Mailing Address - Street 2:SUITE 6
Mailing Address - City:EVANSTON
Mailing Address - State:WY
Mailing Address - Zip Code:82930-8752
Mailing Address - Country:US
Mailing Address - Phone:307-783-8361
Mailing Address - Fax:307-783-8399
Practice Address - Street 1:196 ARROWHEAD DR
Practice Address - Street 2:SUITE 6
Practice Address - City:EVANSTON
Practice Address - State:WY
Practice Address - Zip Code:82930-8752
Practice Address - Country:US
Practice Address - Phone:307-783-8361
Practice Address - Fax:307-783-8399
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2012-05-23
Last Update Date:2013-04-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NMMD2012-0060208600000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes208600000XAllopathic & Osteopathic PhysiciansSurgeryGroup - Single Specialty