Provider Demographics
NPI:1548462856
Name:KENNETH C. TAM, M.D., F.A.C.C., P.C.
Entity type:Organization
Organization Name:KENNETH C. TAM, M.D., F.A.C.C., P.C.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OFFICE MANAGER
Authorized Official - Prefix:
Authorized Official - First Name:LUCY
Authorized Official - Middle Name:
Authorized Official - Last Name:DAI
Authorized Official - Suffix:
Authorized Official - Credentials:RN
Authorized Official - Phone:212-233-8813
Mailing Address - Street 1:217 GRAND ST
Mailing Address - Street 2:9TH FLOOR
Mailing Address - City:NEW YORK
Mailing Address - State:NY
Mailing Address - Zip Code:10013-4286
Mailing Address - Country:US
Mailing Address - Phone:212-233-8813
Mailing Address - Fax:212-267-3303
Practice Address - Street 1:217 GRAND ST
Practice Address - Street 2:9TH FLOOR
Practice Address - City:NEW YORK
Practice Address - State:NY
Practice Address - Zip Code:10013-4286
Practice Address - Country:US
Practice Address - Phone:212-233-8813
Practice Address - Fax:212-267-3303
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-05-31
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY173277174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes174400000XOther Service ProvidersSpecialistGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY01485625Medicaid
NY97F661Medicare ID - Type Unspecified
NY01485625Medicaid