Provider Demographics
NPI:1841239746
Name:TANN, MARK (MD)
Entity Type:Individual
Prefix:
First Name:MARK
Middle Name:
Last Name:TANN
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 1:714 N SENATE AVE
Practice Address - Street 2:SUITE 250
Practice Address - City:INDIANAPOLIS
Practice Address - State:IN
Practice Address - Zip Code:46202-3763
Practice Address - Country:US
Practice Address - Phone:317-715-6402
Practice Address - Fax:317-715-6415
Is Sole Proprietor?:No
Enumeration Date:2006-06-06
Last Update Date:2021-03-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN01056509A207UN0902X, 2085R0202X, 2085N0904X, 207UN0902X, 2085R0202X, 2085N0904X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2085N0904XAllopathic & Osteopathic PhysiciansRadiologyNuclear Radiology
No207UN0902XAllopathic & Osteopathic PhysiciansNuclear MedicineNuclear Imaging & Therapy
No2085R0202XAllopathic & Osteopathic PhysiciansRadiologyDiagnostic Radiology
Provider Identifiers
StateIdentifier IDID TypeIssuer
INP00195774OtherRAILROAD MEDICARE
IN200406300Medicaid
INP00108643OtherRAIL ROAD MEDICARE
IN219950FMedicare PIN
IN200406300Medicaid
IN959090L8Medicare PIN