Provider Demographics
NPI:1023299799
Name:TAN, KELLY KEH LIH (MD)
Entity type:Individual
Prefix:
First Name:KELLY
Middle Name:KEH LIH
Last Name:TAN
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:KEH-LIH
Other - Middle Name:
Other - Last Name:TORN
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:MD
Mailing Address - Street 1:3880 SALEM LAKE DR
Mailing Address - Street 2:STE F
Mailing Address - City:LONG GROVE
Mailing Address - State:IL
Mailing Address - Zip Code:60047-5292
Mailing Address - Country:US
Mailing Address - Phone:847-719-2220
Mailing Address - Fax:847-719-2265
Practice Address - Street 1:3880 SALEM LAKE DR
Practice Address - Street 2:STE F
Practice Address - City:LONG GROVE
Practice Address - State:IL
Practice Address - Zip Code:60047-5292
Practice Address - Country:US
Practice Address - Phone:847-719-2220
Practice Address - Fax:847-719-2265
Is Sole Proprietor?:No
Enumeration Date:2007-11-21
Last Update Date:2023-03-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL036119745208M00000X
IL125049167207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
No208M00000XAllopathic & Osteopathic PhysiciansHospitalist
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL036119745Medicaid
FT0898176OtherDEA