MEDICARE: DR. MADELINE P TAN M.D.

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	208000000X	Pediatrics Physician	35647	KY
2	208000000X	Pediatrics Physician	25MA06846600	NJ

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
2	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program

General Provider Information

NPI Number	:	1720068414
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	DR. MADELINE P TAN M.D.

Provider Business Mailing Address
First Line	:	6601 VENTNOR AVE
Second Line	:	SUITE #14
City	:	VENTNOR CITY
State	:	NJ
Zip	:	08406
Country	:	US
Telephone Number	:	609-487-6507
Fax Number	:	609-487-6508

Provider Business Practice Location Address
First Line	:	6601 VENTNOR AVE
Second Line	:	SUITE #14
City	:	VENTNOR CITY
State	:	NJ
Zip	:	08406
Country	:	US
Telephone Number	:	609-487-6507
Fax Number	:	609-487-6508

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

Provider Enumeration Date	:	01/19/2006
Last Update Date	:	10/05/2012

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