MEDICARE: PETER X. TAN MEDICAL CORPORATION

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	207R00000X	Internal Medicine Physician	A69134	CA

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program

General Provider Information

NPI Number	:	1649322975
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	PETER X. TAN MEDICAL CORPORATION

Provider Business Mailing Address
First Line	:	1990 SIERRA MADRE VILLA AVE
Second Line	:
City	:	PASADENA
State	:	CA
Zip	:	91107-1235
Country	:	US
Telephone Number	:	626-354-9113
Fax Number	:	626-389-5055

Provider Business Practice Location Address
First Line	:	1990 SIERRA MADRE VILLA AVE
Second Line	:
City	:	PASADENA
State	:	CA
Zip	:	91107-1235
Country	:	US
Telephone Number	:	626-354-9113
Fax Number	:	626-389-5055

Authorized Official
Title or Position	:	PRESIDENT
Name	:	PETER X. TAN
Credential	:	M.D.
Telephone Number	:	626-354-9113

Provider Enumeration Date	:	01/17/2007
Last Update Date	:	12/07/2017

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