Basic Information
| Provider Information | |||||||||
| NPI: | 1922096627 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | TAN | ||||||||
| FirstName: | BENG | ||||||||
| MiddleName: | JIT | ||||||||
| NamePrefix: | DR. | ||||||||
| NameSuffix: | |||||||||
| Credential: | MD, PHD | ||||||||
| OtherOrganizationName: | |||||||||
| OtherOrganizationType: | |||||||||
| OtherLastName: | |||||||||
| OtherFirstName: | |||||||||
| OtherMiddleName: | |||||||||
| OtherNamePrefix: | |||||||||
| OtherNameSuffix: | |||||||||
| OtherCredential: | |||||||||
| OtherLastNameType: | |||||||||
| Mailing Information | |||||||||
| Address1: | 346 GRAND AVE | ||||||||
| Address2: | |||||||||
| City: | JOHNSON CITY | ||||||||
| State: | NY | ||||||||
| PostalCode: | 137902541 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6077298156 | ||||||||
| FaxNumber: | 6077292209 | ||||||||
| Practice Location | |||||||||
| Address1: | 30 HARRISON ST | ||||||||
| Address2: | SUITE 460 | ||||||||
| City: | JOHNSON CITY | ||||||||
| State: | NY | ||||||||
| PostalCode: | 137902161 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6077638101 | ||||||||
| FaxNumber: | 6077638049 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 10/07/2005 | ||||||||
| LastUpdateDate: | 04/21/2017 | ||||||||
| NPIDeactivationReasonCode: | |||||||||
| NPIDeactivationDate: | |||||||||
| NPIReactivationDate: | |||||||||
| ProviderGenderCode: | M | ||||||||
| AuthorizedOfficialLastName: | |||||||||
| AuthorizedOfficialFirstName: | |||||||||
| AuthorizedOfficialMiddleName: | |||||||||
| AuthorizedOfficialTitleorPosition: | |||||||||
| AuthorizedOfficialTelephone: | |||||||||
| IsSoleProprietor: | N | ||||||||
| IsOrganizationSubpart: | |||||||||
| ParentOrganizationLBN: | |||||||||
| AuthorizedOfficialNamePrefix: | |||||||||
| AuthorizedOfficialNameSuffix: | |||||||||
| AuthorizedOfficialCredential: | |||||||||
| NPICertificationDate: | |||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 208800000X | 231029 | NY | Y | Allopathic & Osteopathic Physicians | Urology | 208D00000X | 231029 | NY | N | Allopathic & Osteopathic Physicians | General Practice |
ID Information
| ID | Type | State | Issuer | Description | P010231029 | 01 | NY | MONROE | OTHER | 2678971 | 05 | NY | MEDICAID | 40403006189 | 01 | NY | FIDELIS | OTHER | 928140001 | 01 | NY | HEALTH NOW | OTHER | P010231029 | 01 | NY | FAMILY HEALTH PLUS | OTHER | 27164801 | 01 | NY | UNIVERA | OTHER | 1000741 | 01 | NY | GHI | OTHER | MDJ211 | 01 | NY | PREFERRED CARE | OTHER | 1913021 | 01 | NY | IHA | OTHER | 7238658 | 01 | NY | AETNA | OTHER |