Provider Demographics
NPI:1255396966
Name:TANAMACHI, VINCENT P (MD)
Entity type:Individual
Prefix:
First Name:VINCENT
Middle Name:P
Last Name:TANAMACHI
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
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Other - Last Name:
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Other - Credentials:
Mailing Address - Street 1:PO BOX 776351
Mailing Address - Street 2:
Mailing Address - City:CHICAGO
Mailing Address - State:IL
Mailing Address - Zip Code:60677-6351
Mailing Address - Country:US
Mailing Address - Phone:502-588-9490
Mailing Address - Fax:502-272-5116
Practice Address - Street 1:3101 POPLAR LEVEL RD STE 101
Practice Address - Street 2:
Practice Address - City:LOUISVILLE
Practice Address - State:KY
Practice Address - Zip Code:40213-1076
Practice Address - Country:US
Practice Address - Phone:502-636-7444
Practice Address - Fax:502-636-7112
Is Sole Proprietor?:No
Enumeration Date:2006-04-18
Last Update Date:2024-04-12
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
KY28178207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
KY048229OtherSIHO / NCMA
000000350822OtherANTHEM - NMCA
KY000014952VOtherHUMANA / NCMA
KYP00193395OtherMEDICARE RAILROAD
KY7617604OtherCIGNA / NCMA
2446864000OtherPAD - NCMA
KY1184325OtherCHA / NCMA
50005560OtherPASSPORT - NCMA
KY64281785Medicaid
KY64281785Medicaid
KY1361930Medicare PIN