Basic Information
| Provider Information | |||||||||
| NPI: | 1265471841 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | TAN | ||||||||
| FirstName: | HONGJING | ||||||||
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| Credential: | MD | ||||||||
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| Mailing Information | |||||||||
| Address1: | 2251 N SHORE DR | ||||||||
| Address2: | SUITE 100 | ||||||||
| City: | RHINELANDER | ||||||||
| State: | WI | ||||||||
| PostalCode: | 545016710 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7153614700 | ||||||||
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| Practice Location | |||||||||
| Address1: | 1020 KABEL AVE | ||||||||
| Address2: | |||||||||
| City: | RHINELANDER | ||||||||
| State: | WI | ||||||||
| PostalCode: | 545013918 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7153614700 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 06/06/2006 | ||||||||
| LastUpdateDate: | 12/15/2021 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 208100000X | 42160 | WI | Y | Allopathic & Osteopathic Physicians | Physical Medicine & Rehabilitation |
ID Information
| ID | Type | State | Issuer | Description | 34103400 | 05 | WI | MEDICAID |