1285666818 NPI number — TERRY MARIE TAN DPM

Table of content: FARAH FAIZA (NPI 1396572475)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1285666818 NPI number — TERRY MARIE TAN DPM

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
TAN
Provider First Name:
TERRY
Provider Middle Name:
MARIE
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
DPM
Provider Gender Code:
F

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1285666818
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
08/08/2022
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
5730 EXECUTIVE DR STE 230
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
CATONSVILLE
Provider Business Mailing Address State Name:
MD
Provider Business Mailing Address Postal Code:
21228-1762
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
410-402-2379
Provider Business Mailing Address Fax Number:

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
711 MAIDEN CHOICE LN
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
BALTIMORE
Provider Business Practice Location Address State Name:
MD
Provider Business Practice Location Address Postal Code:
21228-3632
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
410-247-5602
Provider Business Practice Location Address Fax Number:
410-242-1756
Provider Enumeration Date:
07/06/2006

Additional Information

Authorized Official

Authorized Official Last Name:
Authorized Official First Name:
Authorized Official Middle Name:
Authorized Official Title or Position:
Authorized Official Telephone Number:

Provider Taxonomy Codes

  • Taxonomy code: 213E00000X , with the licence number:  01320 , registered in the state of MD ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)

  • Identifier: 138CER-610595-07 . This is a "CAREFIRST BCBS OF MD" identifier . This identifiers is of the category "OTHER".
  • Identifier: 008203100 , issued by the state of ( MD ) . This identifiers is of the category "MEDICAID".
  • Identifier: 2701161 . This is a "EVERCARE" identifier . This identifiers is of the category "OTHER".
  • Identifier: 610595-07 . This is a "BCBS MD" identifier . This identifiers is of the category "OTHER".
  • Identifier: 0045 . This is a "CAREFIRST" identifier . This identifiers is of the category "OTHER".
  • Identifier: 0943ER-610595-07 . This is a "CAREFIRST BCBS OF MD" identifier . This identifiers is of the category "OTHER".
  • Identifier: 008203101 , issued by the state of ( MD ) . This identifiers is of the category "MEDICAID".
  • Identifier: 008203102 , issued by the state of ( MD ) . This identifiers is of the category "MEDICAID".




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