1225112196 NPI number — DR. BENJAMIN B TANG M.D.

Table of content: DR. BENJAMIN B TANG M.D. (NPI 1225112196)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1225112196 NPI number — DR. BENJAMIN B TANG M.D.

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
TANG
Provider First Name:
BENJAMIN
Provider Middle Name:
B
Provider Name Prefix Text:
DR.
Provider Name Suffix Text:
Provider Credential Text:
M.D.
Provider Gender Code:
M

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:
1225112196
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
12/06/2018
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
PO BOX 451
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
NORTHBROOK
Provider Business Mailing Address State Name:
IL
Provider Business Mailing Address Postal Code:
60065-0451
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
847-593-8460
Provider Business Mailing Address Fax Number:
224-235-4652

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
333 W 89TH AVE STE W2
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
MERRILLVILLE
Provider Business Practice Location Address State Name:
IN
Provider Business Practice Location Address Postal Code:
46410
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
317-671-7460
Provider Business Practice Location Address Fax Number:
224-235-4652
Provider Enumeration Date:
10/25/2006

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: 208G00000X , with the licence number:  036055168 , registered in the state of IL ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 208G00000X , with the licence number: 01033529A , registered in the state of IN ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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

  • Identifier: 351859903012 . This is a "BLUE SHIELD WI" identifier , issued by the state of ( WI ) . This identifiers is of the category "OTHER".
  • Identifier: 330002905 . This is a "RAILROAD MEDICARE PART B" identifier . This identifiers is of the category "OTHER".
  • Identifier: 911-08127 . This is a "BLUE SHIELD IL" identifier , issued by the state of ( IL ) . This identifiers is of the category "OTHER".
  • Identifier: 000000077842 . This is a "ANTHEM BCBS IN" identifier , issued by the state of ( IN ) . This identifiers is of the category "OTHER".
  • Identifier: 100203000A , issued by the state of ( IN ) . This identifiers is of the category "MEDICAID".
  • Identifier: 351859903 . This is a "ILLINOIS PULIC AID" identifier , issued by the state of ( IL ) . This identifiers is of the category "OTHER".




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