Provider Demographics
NPI:1972009249
Name:TANIOUS, MICHAEL
Entity Type:Individual
Prefix:
First Name:MICHAEL
Middle Name:
Last Name:TANIOUS
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1775 BALLARD RD
Mailing Address - Street 2:
Mailing Address - City:PARK RIDGE
Mailing Address - State:IL
Mailing Address - Zip Code:60068-1005
Mailing Address - Country:US
Mailing Address - Phone:847-318-9340
Mailing Address - Fax:
Practice Address - Street 1:1775 BALLARD RD
Practice Address - Street 2:
Practice Address - City:PARK RIDGE
Practice Address - State:IL
Practice Address - Zip Code:60068
Practice Address - Country:US
Practice Address - Phone:847-318-9340
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2018-04-04
Last Update Date:2018-06-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL125.072169207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine