Healthcare Provider Details

I. General information

NPI: 1083684500
Provider Name (Legal Business Name): IRENE J. TAN M.D.
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

Provider Other Name: IRENE J. TAN M.D.

II. Dates (important events)

Enumeration Date: 01/26/2006
Last Update Date: 11/06/2020
Certification Date: 11/06/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

9880 BUSTLETON AVE
PHILADELPHIA PA
19115-2185
US

IV. Provider business mailing address

2450 W HUNTING PARK AVE
PHILADELPHIA PA
19129-1302
US

V. Phone/Fax

Practice location:
  • Phone: 215-827-1500
  • Fax: 215-827-1501
Mailing address:
  • Phone: 215-707-4600
  • Fax: 215-707-4034

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207RR0500X
TaxonomyRheumatology Physician
License NumberMD445427
License Number StatePA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: