Provider Demographics
NPI:1942390919
Name:TALLAN, ERIC MICHAEL (MD)
Entity Type:Individual
Prefix:DR
First Name:ERIC
Middle Name:MICHAEL
Last Name:TALLAN
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 1:315 ILLINOIS ST
Mailing Address - Street 2:
Mailing Address - City:FAIRBANKS
Mailing Address - State:AK
Mailing Address - Zip Code:99701-2910
Mailing Address - Country:US
Mailing Address - Phone:907-456-7768
Mailing Address - Fax:907-456-8050
Practice Address - Street 1:1919 LATHROP ST.
Practice Address - Street 2:STE 207
Practice Address - City:FAIRBANKS
Practice Address - State:AK
Practice Address - Zip Code:99701
Practice Address - Country:US
Practice Address - Phone:907-456-7768
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-10-13
Last Update Date:2010-12-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AK3111207Y00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Y00000XAllopathic & Osteopathic PhysiciansOtolaryngology
Provider Identifiers
StateIdentifier IDID TypeIssuer
AK040006075OtherMEDICARE RR
AKMD0112Medicaid
AKK04WCKDJDMedicare PIN