Provider Demographics
NPI:1306587266
Name:TANIS, DIRK (DO)
Entity type:Individual
Prefix:
First Name:DIRK
Middle Name:
Last Name:TANIS
Suffix:
Gender:M
Credentials:DO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:200 JEFFERSON AVE SE
Mailing Address - Street 2:
Mailing Address - City:GRAND RAPIDS
Mailing Address - State:MI
Mailing Address - Zip Code:49503-4502
Mailing Address - Country:US
Mailing Address - Phone:616-685-6867
Mailing Address - Fax:
Practice Address - Street 1:1130 W MICHIGAN ST
Practice Address - Street 2:
Practice Address - City:INDIANAPOLIS
Practice Address - State:IN
Practice Address - Zip Code:46202-5149
Practice Address - Country:US
Practice Address - Phone:317-944-5000
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2022-04-05
Last Update Date:2023-06-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI5151015444207L00000X
IN11022758A207L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207L00000XAllopathic & Osteopathic PhysiciansAnesthesiology