Provider Demographics
NPI:1992961148
Name:PAT TANA, M.D., PA
Entity type:Organization
Organization Name:PAT TANA, M.D., PA
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:PAT
Authorized Official - Middle Name:
Authorized Official - Last Name:TANA
Authorized Official - Suffix:
Authorized Official - Credentials:MD, PA
Authorized Official - Phone:410-922-1661
Mailing Address - Street 1:5400 OLD COURT RD
Mailing Address - Street 2:SUITE 101
Mailing Address - City:RANDALLSTOWN
Mailing Address - State:MD
Mailing Address - Zip Code:21133-5100
Mailing Address - Country:US
Mailing Address - Phone:410-922-1661
Mailing Address - Fax:410-922-0365
Practice Address - Street 1:5400 OLD COURT RD
Practice Address - Street 2:SUITE 101
Practice Address - City:RANDALLSTOWN
Practice Address - State:MD
Practice Address - Zip Code:21133-5100
Practice Address - Country:US
Practice Address - Phone:410-922-1661
Practice Address - Fax:410-922-0365
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-08-06
Last Update Date:2009-01-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MDD21797174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes174400000XOther Service ProvidersSpecialistGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
MD979801300Medicaid
MD6653Medicare PIN
MD979801300Medicaid