Provider Demographics
NPI:1083684500
Name:TAN, IRENE J (MD)
Entity type:Individual
Prefix:DR
First Name:IRENE
Middle Name:J
Last Name:TAN
Suffix:
Gender:F
Credentials:MD
Other - Prefix:DR
Other - First Name:IRENE
Other - Middle Name:J
Other - Last Name:TAN
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:MD
Mailing Address - Street 1:2450 W HUNTING PARK AVE
Mailing Address - Street 2:
Mailing Address - City:PHILADELPHIA
Mailing Address - State:PA
Mailing Address - Zip Code:19129-1302
Mailing Address - Country:US
Mailing Address - Phone:215-707-4600
Mailing Address - Fax:215-707-4034
Practice Address - Street 1:9880 BUSTLETON AVE
Practice Address - Street 2:
Practice Address - City:PHILADELPHIA
Practice Address - State:PA
Practice Address - Zip Code:19115-2185
Practice Address - Country:US
Practice Address - Phone:215-827-1500
Practice Address - Fax:215-827-1501
Is Sole Proprietor?:Yes
Enumeration Date:2006-01-26
Last Update Date:2020-11-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PAMD445427207RR0500X, 207RR0500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RR0500XAllopathic & Osteopathic PhysiciansInternal MedicineRheumatology
Provider Identifiers
StateIdentifier IDID TypeIssuer
CT1891982005OtherGROUP NPI
CTC03453OtherMEDICARE GROUP PIN
CT010037521CT01OtherBCBS PROVIDER ID
CT2V7063OtherHEALTH NET PROVIDER ID
CTH00622Medicare UPIN
CT660000055Medicare PIN