Provider Demographics
NPI:1770556045
Name:TAN, MICHAEL (MD)
Entity type:Individual
Prefix:DR
First Name:MICHAEL
Middle Name:
Last Name:TAN
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 1:1617 N JAMES ST
Mailing Address - Street 2:SUITE 900
Mailing Address - City:ROME
Mailing Address - State:NY
Mailing Address - Zip Code:13440-2848
Mailing Address - Country:US
Mailing Address - Phone:315-337-2903
Mailing Address - Fax:315-337-6253
Practice Address - Street 1:1617 N JAMES ST
Practice Address - Street 2:SUITE 900
Practice Address - City:ROME
Practice Address - State:NY
Practice Address - Zip Code:13440-2848
Practice Address - Country:US
Practice Address - Phone:315-337-2903
Practice Address - Fax:315-337-6253
Is Sole Proprietor?:Yes
Enumeration Date:2006-02-08
Last Update Date:2008-06-30
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
NY1378671207X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207X00000XAllopathic & Osteopathic PhysiciansOrthopaedic Surgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY1040426013829OtherFIDELLS CARE NY
NY111530400OtherUS DEPT OF LABOR
NY00582027Medicaid
NY185034OtherMVP HEALTH CARE
NYRB8556Medicare PIN
NY1040426013829OtherFIDELLS CARE NY
D02158Medicare UPIN