Provider Demographics
NPI:1770710105
Name:TAN, CORINNE (MD)
Entity type:Individual
Prefix:
First Name:CORINNE
Middle Name:
Last Name:TAN
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1465S. GRAND BOULEVARD
Mailing Address - Street 2:GLENNON HALL 5727
Mailing Address - City:SAINT LOUIS
Mailing Address - State:MO
Mailing Address - Zip Code:63104
Mailing Address - Country:US
Mailing Address - Phone:314-268-4180
Mailing Address - Fax:
Practice Address - Street 1:1465 S GRAND BLVD
Practice Address - Street 2:
Practice Address - City:SAINT LOUIS
Practice Address - State:MO
Practice Address - Zip Code:63104-1003
Practice Address - Country:US
Practice Address - Phone:314-268-4180
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2009-06-11
Last Update Date:2021-03-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO20200360602086S0120X, 208G00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208G00000XAllopathic & Osteopathic PhysiciansThoracic Surgery (Cardiothoracic Vascular Surgery)
No2086S0120XAllopathic & Osteopathic PhysiciansSurgeryPediatric Surgery