Healthcare Provider Details

I. General information

NPI: 1568410587
Provider Name (Legal Business Name): KEJIAN TANG M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 05/04/2006
Last Update Date: 01/26/2015
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

181 MAPLE ST
MASSENA NY
13662-1012
US

IV. Provider business mailing address

1 HOSPITAL DRIVE
MASSENA NY
13662
US

V. Phone/Fax

Practice location:
  • Phone: 315-842-3095
  • Fax: 315-842-3035
Mailing address:
  • Phone: 315-769-4200
  • Fax: 315-769-4353

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code174400000X
TaxonomySpecialist
License NumberE4568
License Number StateAR
# 2
Primary TaxonomyY
Taxonomy Code2084N0400X
TaxonomyNeurology Physician
License Number224356-1
License Number StateNY
# 3
Primary TaxonomyN
Taxonomy Code2084N0400X
TaxonomyNeurology Physician
License NumberE-4568
License Number StateAK

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: