Basic Information
Provider Information | |||||||||
NPI: | 1508961319 | ||||||||
EntityType: | 1 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: |   | ||||||||
LastName: | TAHN | ||||||||
FirstName: | CARL | ||||||||
MiddleName: |   | ||||||||
NamePrefix: |   | ||||||||
NameSuffix: |   | ||||||||
Credential: | M.D. | ||||||||
OtherOrganizationName: |   | ||||||||
OtherOrganizationType: |   | ||||||||
OtherLastName: |   | ||||||||
OtherFirstName: |   | ||||||||
OtherMiddleName: |   | ||||||||
OtherNamePrefix: |   | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: |   | ||||||||
OtherLastNameType: |   | ||||||||
Mailing Information | |||||||||
Address1: | 908 W 4TH NORTH ST | ||||||||
Address2: |   | ||||||||
City: | MORRISTOWN | ||||||||
State: | TN | ||||||||
PostalCode: | 378143894 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 4234926100 | ||||||||
FaxNumber: | 4234926101 | ||||||||
Practice Location | |||||||||
Address1: | 107 LONGWOOD AVE | ||||||||
Address2: |   | ||||||||
City: | ROCKLEDGE | ||||||||
State: | FL | ||||||||
PostalCode: | 32955 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 3216362111 | ||||||||
FaxNumber: | 3216367180 | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 09/14/2006 | ||||||||
LastUpdateDate: | 01/31/2022 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: | M | ||||||||
AuthorizedOfficialLastName: |   | ||||||||
AuthorizedOfficialFirstName: |   | ||||||||
AuthorizedOfficialMiddleName: |   | ||||||||
AuthorizedOfficialTitleorPosition: |   | ||||||||
AuthorizedOfficialTelephone: |   | ||||||||
IsSoleProprietor: | N | ||||||||
IsOrganizationSubpart: |   | ||||||||
ParentOrganizationLBN: |   | ||||||||
AuthorizedOfficialNamePrefix: |   | ||||||||
AuthorizedOfficialNameSuffix: |   | ||||||||
AuthorizedOfficialCredential: |   | ||||||||
NPICertificationDate: | 01/31/2022 |
Taxonomy Information
Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207RH0003X | 2018033152 | MO | N |   | Allopathic & Osteopathic Physicians | Internal Medicine | Hematology & Oncology | 207RH0003X | M-2288 | GU | N |   | Allopathic & Osteopathic Physicians | Internal Medicine | Hematology & Oncology | 207RH0003X | 89137 | FL | Y |   | Allopathic & Osteopathic Physicians | Internal Medicine | Hematology & Oncology |
ID Information
ID | Type | State | Issuer | Description | 268516700 | 05 | FL |   | MEDICAID | Q031435 | 05 | TN |   | MEDICAID |