1366734717 NPI number — DR. GARY TAN D.O.

Table of content: DR. GARY TAN D.O. (NPI 1366734717)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1366734717 NPI number — DR. GARY TAN D.O.

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
TAN
Provider First Name:
GARY
Provider Middle Name:
Provider Name Prefix Text:
DR.
Provider Name Suffix Text:
Provider Credential Text:
D.O.
Provider Gender Code:
M

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1366734717
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
04/03/2020
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
380 SUMMIT AVE., MSO PHYSICIAN BILLING
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
STEUBENVILLE
Provider Business Mailing Address State Name:
OH
Provider Business Mailing Address Postal Code:
43952-2667
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
740-283-7597
Provider Business Mailing Address Fax Number:
740-283-7460

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
1 ROSS PARK BLVD STE G-3
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
STEUBENVILLE
Provider Business Practice Location Address State Name:
OH
Provider Business Practice Location Address Postal Code:
43952-2681
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
740-266-5969
Provider Business Practice Location Address Fax Number:
740-266-5970
Provider Enumeration Date:
05/04/2011

Additional Information

Authorized Official

Authorized Official Last Name:
Authorized Official First Name:
Authorized Official Middle Name:
Authorized Official Title or Position:
Authorized Official Telephone Number:

Provider Taxonomy Codes

  • Taxonomy code: 208800000X , with the licence number:  303775 , registered in the state of LA ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 208800000X , with the licence number: 25MB09553900 , registered in the state of NJ ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 208800000X , with the licence number: 12699 , registered in the state of OH ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 208800000X , with the licence number: 3182 , registered in the state of WV ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 208800000X , with the licence number: 34.012699 , registered in the state of OH ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)

  • Identifier: 0244510 , issued by the state of ( OH ) . This identifiers is of the category "MEDICAID".




Copyright © 2007-2025 www.npivalidator.com