Basic Information
| Provider Information | |||||||||
| NPI: | 1851612204 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | BANG | ||||||||
| FirstName: | TAMI | ||||||||
| MiddleName: | JESSICA | ||||||||
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| Credential: | M.D. | ||||||||
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| Mailing Information | |||||||||
| Address1: | 1400 JACKSON ST | ||||||||
| Address2: | GRADUATE MEDICAL EDUCATION PROGRAM | ||||||||
| City: | DENVER | ||||||||
| State: | CO | ||||||||
| PostalCode: | 802062761 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3033884461 | ||||||||
| FaxNumber: | 3032702174 | ||||||||
| Practice Location | |||||||||
| Address1: | 12605 E 16TH AVE | ||||||||
| Address2: | |||||||||
| City: | AURORA | ||||||||
| State: | CO | ||||||||
| PostalCode: | 800452545 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7208480000 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 06/21/2010 | ||||||||
| LastUpdateDate: | 07/21/2022 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 2085R0202X | 55053 | CO | Y | Allopathic & Osteopathic Physicians | Radiology | Diagnostic Radiology | 390200000X | TL-3678 | CO | N | Student, Health Care | Student in an Organized Health Care Education/Training Program |
ID Information
| ID | Type | State | Issuer | Description | 63430771 | 05 | CO | MEDICAID |