Mitchell Glenn Eustaquio Tan, DNP, APRN,PMHNP-BC

Primary specialty

Psychiatric/Mental Health Nurse PractitionerTaxonomy code 363LP0808X

License

209031254 Issued in IL

Practice address

1639 N Alpine Rd Ste 260
Rockford, IL 61107-1481

Phone

(815) 670-1715

NPI assigned

Oct 14, 2024

Sex

Male

Sole proprietor

Yes

Registry information is reported by the provider to CMS and is not verified. About this source

Specialties & licenses 4

Addresses

Medicare fee-for-service enrollment

Enrolled in IL

Eligible to order & refer

• Part B services: Yes
• Medical equipment: Yes
• Home health: Yes
• Power mobility devices: Yes
• Hospice: No

Green means eligible to order or refer.

Enrollment records 1

Specialty

Nurse Practitioner

Education

Other, 2024

Medicare assignment

Accepts the Medicare-approved amount as payment in full

Telehealth

Offers telehealth services

Group practices

Rockford Psychiatric Medical Services SCGroup PAC ID 6901089515, 154 clinicians

Practice addresses (Care Compare)

Medicare enrollment (NPD)

Enrolled

State licenses

Practice roles

Locations

Interoperability endpoints

• Direct secure messaging: mitchell.tan.1@25899.direct.athenahealth.com

Organizations this provider is connected to: Medicare benefit reassignments (the organization bills Medicare for this provider’s services), Care Compare group memberships and National Provider Directory roles.

• Rockford Psychiatric Medical Services, S.C.

  • Psychiatry Physician
  • Rockford, IL
  • NPI 1821391442
  Medicare reassignment Care Compare group NPD

The complete NPPES record for this NPI in the NPI Registry API format.

{
    "created_epoch": "1728864000000",
    "enumeration_type": "NPI-1",
    "last_updated_epoch": "1742860800000",
    "number": "1518787696",
    "addresses": [
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "MAILING",
            "address_type": "DOM",
            "address_1": "5126 SILVER FOX TRL",
            "city": "ROCKFORD",
            "state": "IL",
            "postal_code": "611147010",
            "telephone_number": "815-670-1715"
        },
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "LOCATION",
            "address_type": "DOM",
            "address_1": "1639 N ALPINE RD STE 260",
            "city": "ROCKFORD",
            "state": "IL",
            "postal_code": "611071481",
            "telephone_number": "815-670-1715"
        }
    ],
    "practiceLocations": [],
    "basic": {
        "last_name": "TAN",
        "first_name": "MITCHELL GLENN",
        "middle_name": "EUSTAQUIO",
        "name_prefix": "Dr.",
        "credential": "DNP, APRN,PMHNP-BC",
        "sole_proprietor": "YES",
        "sex": "M",
        "enumeration_date": "2024-10-14",
        "last_updated": "2025-03-25",
        "certification_date": "2025-03-25",
        "status": "A"
    },
    "taxonomies": [
        {
            "code": "363LP0808X",
            "taxonomy_group": "",
            "desc": "Nurse Practitioner, Psychiatric/Mental Health",
            "state": "MI",
            "license": "4704421713",
            "primary": false
        },
        {
            "code": "163W00000X",
            "taxonomy_group": "",
            "desc": "Registered Nurse",
            "state": "IL",
            "license": "041502075",
            "primary": false
        },
        {
            "code": "363LP0808X",
            "taxonomy_group": "",
            "desc": "Nurse Practitioner, Psychiatric/Mental Health",
            "state": "WI",
            "license": "1632233",
            "primary": false
        },
        {
            "code": "363LP0808X",
            "taxonomy_group": "",
            "desc": "Nurse Practitioner, Psychiatric/Mental Health",
            "state": "IL",
            "license": "209031254",
            "primary": true
        }
    ],
    "identifiers": [],
    "endpoints": [],
    "other_names": []
}

• Steven Ronald Taddei, AU.D.
• Luis Tafolla
• Dominic Tagler
• Hena Tahir, OD, MS
• Tetsuya Takeuchi, M.D.
• Brenda Marie Tanker
• Ty Alexander Tanker, AU.D.
• Eric Jon Tanner, LCPC
• George Chahine Tannous, M.D.
• Hira Tariq, MD

• Psychiatric/Mental Health Nurse Practitioner in Rockford, IL
• Providers in Rockford, IL by specialty
• Psychiatric/Mental Health Nurse Practitioner in Illinois

• NPPES NPI Registry (CMS): identity, addresses, specialties, licenses, identifiers and endpoints. Last updated by the provider on Mar 25, 2025; self-reported and not verified by CMS. Specialty names from the NUCC taxonomy.
• Medicare enrollment (CMS PECOS): enrollments, PAC IDs and benefit reassignments; Order and Referring.
• Medicare Care Compare (CMS): clinician profile, group practices, facility affiliations, MIPS scores and star ratings.
• National Provider Directory (CMS): practice roles, locations, licenses, networks and endpoints.

Verify at the official NPI Registry.