Basic Information
Provider Information | |||||||||
NPI: | 1760562474 | ||||||||
EntityType: | 1 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: |   | ||||||||
LastName: | FANG | ||||||||
FirstName: | HSIEN TA | ||||||||
MiddleName: |   | ||||||||
NamePrefix: |   | ||||||||
NameSuffix: |   | ||||||||
Credential: | MD | ||||||||
OtherOrganizationName: |   | ||||||||
OtherOrganizationType: |   | ||||||||
OtherLastName: |   | ||||||||
OtherFirstName: |   | ||||||||
OtherMiddleName: |   | ||||||||
OtherNamePrefix: |   | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: |   | ||||||||
OtherLastNameType: |   | ||||||||
Mailing Information | |||||||||
Address1: | 855 MADISON ST | ||||||||
Address2: |   | ||||||||
City: | OAK PARK | ||||||||
State: | IL | ||||||||
PostalCode: | 603024420 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 7084924077 | ||||||||
FaxNumber: | 7083862839 | ||||||||
Practice Location | |||||||||
Address1: | 120 SPALDING DR | ||||||||
Address2: | SUITE 410 | ||||||||
City: | NAPERVILLE | ||||||||
State: | IL | ||||||||
PostalCode: | 605406508 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 6303690780 | ||||||||
FaxNumber: | 6303690886 | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 10/17/2006 | ||||||||
LastUpdateDate: | 05/27/2022 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: | M | ||||||||
AuthorizedOfficialLastName: |   | ||||||||
AuthorizedOfficialFirstName: |   | ||||||||
AuthorizedOfficialMiddleName: |   | ||||||||
AuthorizedOfficialTitleorPosition: |   | ||||||||
AuthorizedOfficialTelephone: |   | ||||||||
IsSoleProprietor: | N | ||||||||
IsOrganizationSubpart: |   | ||||||||
ParentOrganizationLBN: |   | ||||||||
AuthorizedOfficialNamePrefix: |   | ||||||||
AuthorizedOfficialNameSuffix: |   | ||||||||
AuthorizedOfficialCredential: |   | ||||||||
NPICertificationDate: | 05/27/2022 |
Taxonomy Information
Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207RN0300X | 036103303 | IL | Y |   | Allopathic & Osteopathic Physicians | Internal Medicine | Nephrology |
ID Information
ID | Type | State | Issuer | Description | 1616108 | 01 | IL | BLUE CROSS BLUE SHIELD | OTHER | 036103303 | 05 | IL |   | MEDICAID |