Basic Information
| Provider Information | |||||||||
| NPI: | 1306810395 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | TAN | ||||||||
| FirstName: | HIEDILIZA | ||||||||
| MiddleName: | Y | ||||||||
| NamePrefix: | DR. | ||||||||
| NameSuffix: | |||||||||
| Credential: | M.D., | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 688 | ||||||||
| Address2: | |||||||||
| City: | ALCOA | ||||||||
| State: | TN | ||||||||
| PostalCode: | 377010688 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8652731752 | ||||||||
| FaxNumber: | 8652731755 | ||||||||
| Practice Location | |||||||||
| Address1: | 907 E LAMAR ALEXANDER PKWY | ||||||||
| Address2: | |||||||||
| City: | MARYVILLE | ||||||||
| State: | TN | ||||||||
| PostalCode: | 378045015 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8659837211 | ||||||||
| FaxNumber: | 8652731755 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 02/15/2006 | ||||||||
| LastUpdateDate: | 10/07/2011 | ||||||||
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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 | 207R00000X | 36002 | TN | N | Allopathic & Osteopathic Physicians | Internal Medicine | 207RI0200X | 36002 | TN | Y | Allopathic & Osteopathic Physicians | Internal Medicine | Infectious Disease |
ID Information
| ID | Type | State | Issuer | Description | 3872046 | 05 | TN | MEDICAID |