Basic Information
| Provider Information | |||||||||
| NPI: | 1700869229 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | TAN | ||||||||
| FirstName: | RAYMUNDO | ||||||||
| MiddleName: | T | ||||||||
| NamePrefix: | DR. | ||||||||
| NameSuffix: | |||||||||
| Credential: | M.D. | ||||||||
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| Mailing Information | |||||||||
| Address1: | 419 5TH ST NE | ||||||||
| Address2: | |||||||||
| City: | JAMESTOWN | ||||||||
| State: | ND | ||||||||
| PostalCode: | 584013300 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7012521050 | ||||||||
| FaxNumber: | 7019523265 | ||||||||
| Practice Location | |||||||||
| Address1: | 419 5TH ST NE | ||||||||
| Address2: | |||||||||
| City: | JAMESTOWN | ||||||||
| State: | ND | ||||||||
| PostalCode: | 584013300 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7012521050 | ||||||||
| FaxNumber: | 7019523265 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 11/29/2005 | ||||||||
| LastUpdateDate: | 02/06/2008 | ||||||||
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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 | 2085R0202X | 4669 | ND | Y | Allopathic & Osteopathic Physicians | Radiology | Diagnostic Radiology |
ID Information
| ID | Type | State | Issuer | Description | 18514 | 05 | ND | MEDICAID | 01008891 | 01 | PREFERRED ONE | OTHER | 16-11656 | 01 | MEDICA | OTHER | 7207820 | 05 | SD | MEDICAID | 47607 | 01 | HEALTHPARTNERS | OTHER | 13243 | 01 | ND | BLUE SHIELD | OTHER | 46031641458401C003 | 01 | TRICARE | OTHER | 719609 | 01 | AMERICA'S PPO | OTHER |