Provider Demographics
NPI:1265594584
Name:I.A. TANGOREN, M.D., P.L.L.C.
Entity type:Organization
Organization Name:I.A. TANGOREN, M.D., P.L.L.C.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRACTICE ADMINISTRATOR
Authorized Official - Prefix:DR
Authorized Official - First Name:TRACY
Authorized Official - Middle Name:E
Authorized Official - Last Name:BARRETT-TANGOREN
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:315-569-7900
Mailing Address - Street 1:2949 ERIE BLVD E STE 110
Mailing Address - Street 2:
Mailing Address - City:SYRACUSE
Mailing Address - State:NY
Mailing Address - Zip Code:13224-1460
Mailing Address - Country:US
Mailing Address - Phone:315-424-1430
Mailing Address - Fax:315-424-1779
Practice Address - Street 1:2949 ERIE BLVD E STE 110
Practice Address - Street 2:
Practice Address - City:SYRACUSE
Practice Address - State:NY
Practice Address - Zip Code:13224-1460
Practice Address - Country:US
Practice Address - Phone:315-424-1430
Practice Address - Fax:315-424-1779
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-12-14
Last Update Date:2013-09-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY209386-1207N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207N00000XAllopathic & Osteopathic PhysiciansDermatologyGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
NYBA0061Medicare ID - Type UnspecifiedMEDICARE ENTITY PROV#