Basic Information
| Provider Information | |||||||||
| NPI: | 1104893213 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | TAN | ||||||||
| FirstName: | STEPHANIE | ||||||||
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| Credential: | MD | ||||||||
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| Mailing Information | |||||||||
| Address1: | 525 E MARKET ST | ||||||||
| Address2: | PO BOX 2090 | ||||||||
| City: | AKRON | ||||||||
| State: | OH | ||||||||
| PostalCode: | 443041619 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3309960347 | ||||||||
| FaxNumber: | 3309960359 | ||||||||
| Practice Location | |||||||||
| Address1: | 55 ARCH ST STE 1B | ||||||||
| Address2: | |||||||||
| City: | AKRON | ||||||||
| State: | OH | ||||||||
| PostalCode: | 443041436 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3303753315 | ||||||||
| FaxNumber: | 3303753760 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 03/07/2006 | ||||||||
| LastUpdateDate: | 04/24/2013 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207R00000X | 35-06-9271T | OH | Y | Allopathic & Osteopathic Physicians | Internal Medicine |
ID Information
| ID | Type | State | Issuer | Description | 0837182 | 01 | OH | MEDICARE ID | OTHER | 2035256 | 05 | OH | MEDICAID | 577 | 01 | OH | SUMMA INSURANCE | OTHER | 729116 | 01 | OH | BUCKEYE COMMUNITY HEALTH | OTHER |