Provider Demographics
NPI:1255446100
Name:TAGGE, EDWARD (MD)
Entity type:Individual
Prefix:
First Name:EDWARD
Middle Name:
Last Name:TAGGE
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Credentials:
Mailing Address - Street 1:11175 CAMPUS ST
Mailing Address - Street 2:CP-21111
Mailing Address - City:LOMA LINDA
Mailing Address - State:CA
Mailing Address - Zip Code:92354
Mailing Address - Country:US
Mailing Address - Phone:909-558-4619
Mailing Address - Fax:909-558-7978
Practice Address - Street 1:11370 ANDERSON ST
Practice Address - Street 2:SUITE 2100
Practice Address - City:LOMA LINDA
Practice Address - State:CA
Practice Address - Zip Code:92354-3450
Practice Address - Country:US
Practice Address - Phone:909-558-2282
Practice Address - Fax:909-558-2125
Is Sole Proprietor?:No
Enumeration Date:2006-08-20
Last Update Date:2007-09-05
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
SC155162086S0120X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2086S0120XAllopathic & Osteopathic PhysiciansSurgeryPediatric Surgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
SC155165Medicaid
SCE55678Medicare UPIN