MEDICARE: TADGE M KANJO M.D.

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	174400000X	Specialist	41467-020	WI
2	208600000X	Surgery Physician	41467-020	WI
3	208600000X	Surgery Physician	TL1909	WY

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program

General Provider Information

NPI Number	:	1710970058
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	TADGE M KANJO M.D.

Provider Business Mailing Address
First Line	:	196 ARROWHEAD DR
Second Line	:	SUITE 6
City	:	EVANSTON
State	:	WY
Zip	:	82930-8752
Country	:	US
Telephone Number	:	307-783-8398
Fax Number	:	307-783-8399

Provider Business Practice Location Address
First Line	:	196 ARROWHEAD DR
Second Line	:	SUITE 6
City	:	EVANSTON
State	:	WY
Zip	:	82930-8752
Country	:	US
Telephone Number	:	307-783-8398
Fax Number	:	307-783-8399

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	08/23/2005
Last Update Date	:	09/12/2012

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Directions to “ TADGE M KANJO M.D.” Practice Location

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