Healthcare Provider Details

I. General information

NPI: 1790885572
Provider Name (Legal Business Name): IGNATIUS TANG M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 09/22/2006
Last Update Date: 10/23/2014
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1740 W TAYLOR ST DEPT 3462
CHICAGO IL
60612-7232
US

IV. Provider business mailing address

820 S WOOD ST # MC793 462 CSN
CHICAGO IL
60612-4325
US

V. Phone/Fax

Practice location:
  • Phone: 312-704-2885
  • Fax: 312-704-2737
Mailing address:
  • Phone: 312-413-5732
  • Fax: 312-996-7378

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207RN0300X
TaxonomyNephrology Physician
License Number036110985
License Number StateIL
# 2
Primary TaxonomyN
Taxonomy Code208600000X
TaxonomySurgery Physician
License Number036110985
License Number StateIL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: