=====================================================
General NPI Number Information
=====================================================
NPI Number | 1962670562
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | TERRENCE W. TATARCHUK, M.D., P.C.
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 02/15/2008
-----------------------------------------------------
Last Update Date | 02/23/2010
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 8795 PINE RIDGE DR SUITE B
-----------------------------------------------------
City | CADILLAC
-----------------------------------------------------
State | MI
-----------------------------------------------------
Zip | 49601-9777
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 231-775-1306
-----------------------------------------------------
Fax | 231-775-9701
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 8795 PINE RIDGE DR SUITE B
-----------------------------------------------------
City | CADILLAC
-----------------------------------------------------
State | MI
-----------------------------------------------------
Zip | 49601-9777
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 231-775-1306
-----------------------------------------------------
Fax | 231-775-9701
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | OFFICE MANAGER
-----------------------------------------------------
Name | ROSE TOMPKINS
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone | 231-775-1306
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 174400000X
-----------------------------------------------------
Taxonomy Name | Specialist
-----------------------------------------------------
License Number | 4301039879
-----------------------------------------------------
License Number State | MI
-----------------------------------------------------