Provider Demographics
NPI:1053597914
Name:KENDALL P. TABOR, D.P.M
Entity type:Organization
Organization Name:KENDALL P. TABOR, D.P.M
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:OWNER/PODIATRIST
Authorized Official - Prefix:DR
Authorized Official - First Name:KENDALL
Authorized Official - Middle Name:P
Authorized Official - Last Name:TABOR
Authorized Official - Suffix:
Authorized Official - Credentials:DPM
Authorized Official - Phone:906-225-7709
Mailing Address - Street 1:1414 W FAIR AVE
Mailing Address - Street 2:STE 215
Mailing Address - City:MARQUETTE
Mailing Address - State:MI
Mailing Address - Zip Code:49855-2675
Mailing Address - Country:US
Mailing Address - Phone:906-225-7709
Mailing Address - Fax:906-225-7707
Practice Address - Street 1:1414 W FAIR AVE
Practice Address - Street 2:STE 215
Practice Address - City:MARQUETTE
Practice Address - State:MI
Practice Address - Zip Code:49855-2675
Practice Address - Country:US
Practice Address - Phone:906-225-7709
Practice Address - Fax:906-225-7707
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-01-10
Last Update Date:2011-12-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI5901001089213ES0103X, 332B00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes213ES0103XPodiatric Medicine & Surgery Service ProvidersPodiatristFoot & Ankle SurgeryGroup - Single Specialty
No332B00000XSuppliersDurable Medical Equipment & Medical SuppliesGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI2126020Medicaid
MI0753140001Medicare NSC
MIT34101Medicare UPIN
MIOQ31587Medicare PIN