Basic Information
Provider Information
NPI: 1003015736
EntityType: 1
ReplacementNPI:  
OrganizationName:  
LastName: TAN- PEDRES
FirstName: MAUREEN
MiddleName: U
NamePrefix:  
NameSuffix:  
Credential: M.D.
OtherOrganizationName:  
OtherOrganizationType:  
OtherLastName:  
OtherFirstName:  
OtherMiddleName:  
OtherNamePrefix:  
OtherNameSuffix:  
OtherCredential:  
OtherLastNameType:  
Mailing Information
Address1: 100 MICHIGAN ST NE
Address2: MC 845
City: GRAND RAPIDS
State: MI
PostalCode: 495032560
CountryCode: US
TelephoneNumber:  
FaxNumber:  
Practice Location
Address1: 100 MICHIGAN ST NE
Address2: SUITE A721
City: GRAND RAPIDS
State: MI
PostalCode: 495032560
CountryCode: US
TelephoneNumber: 6163913139
FaxNumber: 6163913044
Other Information
ProviderEnumerationDate: 07/12/2007
LastUpdateDate: 02/03/2011
NPIDeactivationReasonCode:  
NPIDeactivationDate:  
NPIReactivationDate:  
ProviderGenderCode: F
AuthorizedOfficialLastName:  
AuthorizedOfficialFirstName:  
AuthorizedOfficialMiddleName:  
AuthorizedOfficialTitleorPosition:  
AuthorizedOfficialTelephone:  
IsSoleProprietor: N
IsOrganizationSubpart:  
ParentOrganizationLBN:  
AuthorizedOfficialNamePrefix:  
AuthorizedOfficialNameSuffix:  
AuthorizedOfficialCredential:  
NPICertificationDate:  

Taxonomy Information
TaxonomyLicenseStateSwitchTaxonomyGroupTaxonomyTypeTaxonomyClassSubSpecialty
207R00000X4301090617MIY Allopathic & Osteopathic PhysiciansInternal Medicine 

No ID Information.


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