Healthcare Provider Details

I. General information

NPI: 1235158536
Provider Name (Legal Business Name): MARY E TANG M.D.
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/18/2006
Last Update Date: 09/30/2013
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

111 COLCHESTER AVE FLETCHER ALLEN HEALTH CARE, PATHOLOGY
BURLINGTON VT
05401-1473
US

IV. Provider business mailing address

111 COLCHESTER AVE FAHC PATHOLOGY ACC-EP1
BURLINGTON VT
05401-1473
US

V. Phone/Fax

Practice location:
  • Phone: 802-847-5121
  • Fax: 802-847-3987
Mailing address:
  • Phone: 802-847-5121
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code207ZP0007X
TaxonomyMolecular Genetic Pathology (Pathology) Physician
License Number042-0008183
License Number StateVT
# 2
Primary TaxonomyN
Taxonomy Code207ZP0102X
TaxonomyAnatomic Pathology & Clinical Pathology Physician
License Number042-0008183
License Number StateVT
# 3
Primary TaxonomyN
Taxonomy Code207ZP0104X
TaxonomyChemical Pathology Physician
License Number042-0008183
License Number StateVT
# 4
Primary TaxonomyY
Taxonomy Code207SC0300X
TaxonomyClinical Cytogenetics Physician
License Number042.0008183
License Number StateVT

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: