Healthcare Provider Details

I. General information

NPI: 1942390919
Provider Name (Legal Business Name): ERIC MICHAEL TALLAN M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 10/13/2006
Last Update Date: 12/09/2010
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1919 LATHROP ST. STE 207
FAIRBANKS AK
99701
US

IV. Provider business mailing address

315 ILLINOIS ST
FAIRBANKS AK
99701-2910
US

V. Phone/Fax

Practice location:
  • Phone: 907-456-7768
  • Fax:
Mailing address:
  • Phone: 907-456-7768
  • Fax: 907-456-8050

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207Y00000X
TaxonomyOtolaryngology Physician
License Number3111
License Number StateAK

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: