Provider Demographics
NPI:1699882084
Name:TAN, ERNESTO (MD)
Entity type:Individual
Prefix:
First Name:ERNESTO
Middle Name:
Last Name:TAN
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:10400 SOUTHWEST HWY LOWR LEVEL
Mailing Address - Street 2:
Mailing Address - City:CHICAGO RIDGE
Mailing Address - State:IL
Mailing Address - Zip Code:60415-2394
Mailing Address - Country:US
Mailing Address - Phone:708-590-8770
Mailing Address - Fax:708-428-4277
Practice Address - Street 1:300 READ ST STE A
Practice Address - Street 2:
Practice Address - City:LOCKPORT
Practice Address - State:IL
Practice Address - Zip Code:60441-3265
Practice Address - Country:US
Practice Address - Phone:815-741-1020
Practice Address - Fax:815-741-1064
Is Sole Proprietor?:No
Enumeration Date:2006-08-23
Last Update Date:2023-08-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL036049705208800000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208800000XAllopathic & Osteopathic PhysiciansUrology
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL3265OtherGROUP MEDICARE PTAN
1467471540OtherGROUP NPI
DF2482OtherRR PTAM
1467471540OtherGROUP NPI