Basic Information
| Provider Information | |||||||||
| NPI: | 1598053340 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | NELSON | ||||||||
| FirstName: | TARA | ||||||||
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| Credential: | D.O. | ||||||||
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| Mailing Information | |||||||||
| Address1: | 15520 19 MILE RD STE 480 | ||||||||
| Address2: | |||||||||
| City: | CLINTON TOWNSHIP | ||||||||
| State: | MI | ||||||||
| PostalCode: | 480386332 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5862281010 | ||||||||
| FaxNumber: | 5862288570 | ||||||||
| Practice Location | |||||||||
| Address1: | 1000 HARRINGTON ST | ||||||||
| Address2: | |||||||||
| City: | MOUNT CLEMENS | ||||||||
| State: | MI | ||||||||
| PostalCode: | 480432920 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5864938195 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 07/14/2011 | ||||||||
| LastUpdateDate: | 04/06/2022 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | Y | ||||||||
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| NPICertificationDate: | 04/06/2022 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207R00000X | 5101019303 | MI | N | Allopathic & Osteopathic Physicians | Internal Medicine | 207RN0300X | 5101019303 | MI | Y | Allopathic & Osteopathic Physicians | Internal Medicine | Nephrology |
No ID Information.