Provider Demographics
NPI:1700918224
Name:FREDERICK S TAN MD
Entity Type:Organization
Organization Name:FREDERICK S TAN MD
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:MD
Authorized Official - Prefix:DR
Authorized Official - First Name:FREDERICK
Authorized Official - Middle Name:
Authorized Official - Last Name:TAN
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:979-775-9483
Mailing Address - Street 1:1705 E 29TH ST
Mailing Address - Street 2:
Mailing Address - City:BRYAN
Mailing Address - State:TX
Mailing Address - Zip Code:77802-1406
Mailing Address - Country:US
Mailing Address - Phone:979-775-9483
Mailing Address - Fax:979-775-9557
Practice Address - Street 1:1705 E 29TH ST
Practice Address - Street 2:
Practice Address - City:BRYAN
Practice Address - State:TX
Practice Address - Zip Code:77802-1406
Practice Address - Country:US
Practice Address - Phone:979-775-9483
Practice Address - Fax:979-775-9557
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-03-10
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXK8511207RN0300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207RN0300XAllopathic & Osteopathic PhysiciansInternal MedicineNephrologyGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX0017GCOtherBLUE CROSS
TX00564MMedicare ID - Type Unspecified
TXF51188Medicare UPIN