Basic Information
| Provider Information | |||||||||
| NPI: | 1063428324 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | TAN | ||||||||
| FirstName: | AILYN | ||||||||
| MiddleName: | U | ||||||||
| NamePrefix: | DR. | ||||||||
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| Credential: | M.D. | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 1145 | ||||||||
| Address2: | |||||||||
| City: | LIBERTYVILLE | ||||||||
| State: | IL | ||||||||
| PostalCode: | 600484145 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8888438475 | ||||||||
| FaxNumber: | 3148496395 | ||||||||
| Practice Location | |||||||||
| Address1: | 5025 N PAULINA ST | ||||||||
| Address2: | |||||||||
| City: | CHICAGO | ||||||||
| State: | IL | ||||||||
| PostalCode: | 606402772 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7739891422 | ||||||||
| FaxNumber: | 7739891447 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 07/31/2006 | ||||||||
| LastUpdateDate: | 11/06/2007 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | Y | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207ZP0102X | IL | Y | Allopathic & Osteopathic Physicians | Pathology | Anatomic Pathology & Clinical Pathology |
ID Information
| ID | Type | State | Issuer | Description | 01632039 | 01 | IL | BLUESHIELD | OTHER |