Provider Demographics
NPI:1629074240
Name:TAN, EDWIN V (MD)
Entity Type:Individual
Prefix:
First Name:EDWIN
Middle Name:V
Last Name:TAN
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:PO BOX 7291
Mailing Address - Street 2:
Mailing Address - City:LEWISTON
Mailing Address - State:ME
Mailing Address - Zip Code:04243-7291
Mailing Address - Country:US
Mailing Address - Phone:207-755-3781
Mailing Address - Fax:207-777-8800
Practice Address - Street 1:2 GREAT FALLS PLZ STE 21
Practice Address - Street 2:
Practice Address - City:AUBURN
Practice Address - State:ME
Practice Address - Zip Code:04210
Practice Address - Country:US
Practice Address - Phone:207-330-3950
Practice Address - Fax:207-330-3955
Is Sole Proprietor?:No
Enumeration Date:2005-06-28
Last Update Date:2018-08-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MEMD14191207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
ME294700099Medicaid
MEMM6272Medicare PIN
ME294700099Medicaid
MEG24496Medicare UPIN
MEMM4849Medicare PIN
ME201826Medicare Oscar/Certification
MECA8775Medicare PIN