Provider Demographics
NPI:1881782126
Name:ERNESTO TAN, M.D.S.C.
Entity type:Organization
Organization Name:ERNESTO TAN, M.D.S.C.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:ERNESTO
Authorized Official - Middle Name:
Authorized Official - Last Name:TAN
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:815-741-1020
Mailing Address - Street 1:2400 GLENWOOD AVE STE 210
Mailing Address - Street 2:
Mailing Address - City:JOLIET
Mailing Address - State:IL
Mailing Address - Zip Code:60435-5498
Mailing Address - Country:US
Mailing Address - Phone:815-741-1020
Mailing Address - Fax:815-741-1064
Practice Address - Street 1:2400 GLENWOOD AVE STE 210
Practice Address - Street 2:
Practice Address - City:JOLIET
Practice Address - State:IL
Practice Address - Zip Code:60435-5498
Practice Address - Country:US
Practice Address - Phone:815-741-1020
Practice Address - Fax:815-741-1064
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-10-11
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL208800000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes208800000XAllopathic & Osteopathic PhysiciansUrologyGroup - Single Specialty