Healthcare Provider Details

I. General information

NPI: 1225112196
Provider Name (Legal Business Name): BENJAMIN B TANG M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 10/25/2006
Last Update Date: 12/06/2018
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

333 W 89TH AVE STE W2
MERRILLVILLE IN
46410
US

IV. Provider business mailing address

PO BOX 451
NORTHBROOK IL
60065-0451
US

V. Phone/Fax

Practice location:
  • Phone: 317-671-7460
  • Fax: 224-235-4652
Mailing address:
  • Phone: 847-593-8460
  • Fax: 224-235-4652

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code208G00000X
TaxonomyThoracic Surgery (Cardiothoracic Vascular Surgery) Physician
License Number036055168
License Number StateIL
# 2
Primary TaxonomyY
Taxonomy Code208G00000X
TaxonomyThoracic Surgery (Cardiothoracic Vascular Surgery) Physician
License Number01033529A
License Number StateIN

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: