MEDICARE: NICHOLAS TAN MD

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	390200000X	Student in an Organized Health Care Education/Training Program
2	207R00000X	Internal Medicine Physician	125.084523	IL

General Provider Information

NPI Number	:	1417643040
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	NICHOLAS TAN MD

Provider Business Mailing Address
First Line	:	180 HARVESTER DR STE 110
Second Line	:
City	:	BURR RIDGE
State	:	IL
Zip	:	60527-6686
Country	:	US
Telephone Number	:	773-702-1150
Fax Number	:

Provider Business Practice Location Address
First Line	:	2650 RIDGE AVE STE 1304
Second Line	:
City	:	EVANSTON
State	:	IL
Zip	:	60201-1700
Country	:	US
Telephone Number	:	847-570-2700
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	04/17/2023
Last Update Date	:	04/23/2026

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