Individual provider Active NPI

Derrick Tam, NP

  • Acute Care Nurse Practitioner
  • New York, NY
National Provider Identifier
1780042630
Registry record updated Jan 23, 2024
On this page

Key facts

NPPES NPI Registry
Primary specialty
Acute Care Nurse PractitionerTaxonomy code 363LA2100X
License
F432636-01 Issued in NY
Practice address
622 W 168TH St PH 5-505
New York, NY 10032-3720
Phone
(347) 466-3566
NPI assigned
Feb 7, 2016
Sex
Male
Sole proprietor
No

NPPES NPI Registry

Updated by the provider on Jan 23, 2024

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

Specialties & licenses 2

Specialty (taxonomy)CodeLicenseStatePrimary
Registered Nurse 163W00000X 705883 NY
Acute Care Nurse Practitioner 363LA2100X F432636-01 NY Primary

Addresses

Primary practice location

622 W 168TH St PH 5-505
New York, NY 10032-3720

Mailing address

9 Comstock Ave
Staten Island, NY 10314-1404
Phone (347) 466-3566

Medicare participation

Medicare enrollment files
Medicare fee-for-service enrollment
Enrolled in NY
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

Enrollment IDStateProvider typePAC IDDetails
I20240212003371 NY Practitioner - Nurse Practitioner 5991148462 Reassigns benefits to 1 organization

Care Compare profile

Medicare Care Compare
Specialty
Nurse Practitioner
Education
State University of New York Downstate Medical Center, 2020
Medicare assignment
Accepts the Medicare-approved amount as payment in full
Group practices

Practice addresses (Care Compare)

622 W 168TH St
New York, NY 10032-3720
Phone (212) 305-9876

Hospital & facility affiliations

National Provider Directory

National Provider Directory
Medicare enrollment (NPD)
Enrolled
Credentials
Nurse Practitioner

State licenses

LicenseStateTypeSpecialty
705883NYMDRegistered Nurse
F432636-01NYMDAcute Care Nurse Practitioner

Practice roles

OrganizationSpecialtyStatusNew patients
Trustees of Columbia University in the City of New York Acute Care CurrentSince Jan 22, 2024 Accepting new patients
Trustees of Columbia University in the City of New York Current Accepting new patients
Trustees of Columbia University in the City of New York CurrentSince Jan 22, 2024 Accepting new patients

Locations

622 W 168th St
New York, NY 10032
Phone (212) 305-4931

161 Fort Washington Ave
New York, NY 10032
Phone (212) 305-8559

622 W 168th St
Ph 5505
New York, NY 10032
Phone (212) 305-6494

Networks

  • Healthfirst Medicare Network H1722
  • Healthfirst Medicare Network H5989
  • Healthfirst Medicare Network H9678
  • Healthfirst Medicare Network H3359

Interoperability endpoints

  • FHIR API: https://epicproxy-pub.et1089.epichosted.com/FHIRProxy/api/FHIR/R4/
  • FHIR API: https://epicproxy-pub.et1089.epichosted.com/FHIRProxy/api/FHIR/DSTU2/

Organizations & group practices 3

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

Hospital & facility affiliations 5

Hospitals and other facilities this clinician is affiliated with according to Medicare Care Compare.

NPI Registry JSON

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

{
    "created_epoch": "1454803200000",
    "enumeration_type": "NPI-1",
    "last_updated_epoch": "1705968000000",
    "number": "1780042630",
    "addresses": [
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "MAILING",
            "address_type": "DOM",
            "address_1": "9 COMSTOCK AVE",
            "city": "STATEN ISLAND",
            "state": "NY",
            "postal_code": "103141404",
            "telephone_number": "347-466-3566"
        },
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "LOCATION",
            "address_type": "DOM",
            "address_1": "622 W 168TH ST PH 5-505",
            "city": "NEW YORK",
            "state": "NY",
            "postal_code": "100323720",
            "telephone_number": "347-466-3566"
        }
    ],
    "practiceLocations": [],
    "basic": {
        "last_name": "TAM",
        "first_name": "DERRICK",
        "name_prefix": "Mr.",
        "credential": "NP",
        "sole_proprietor": "NO",
        "sex": "M",
        "enumeration_date": "2016-02-07",
        "last_updated": "2024-01-23",
        "certification_date": "2024-01-23",
        "status": "A"
    },
    "taxonomies": [
        {
            "code": "163W00000X",
            "taxonomy_group": "",
            "desc": "Registered Nurse",
            "state": "NY",
            "license": "705883",
            "primary": false
        },
        {
            "code": "363LA2100X",
            "taxonomy_group": "",
            "desc": "Nurse Practitioner, Acute Care",
            "state": "NY",
            "license": "F432636-01",
            "primary": true
        }
    ],
    "identifiers": [],
    "endpoints": [],
    "other_names": []
}

Other providers in New York, NY

Sources for this page

Verify at the official NPI Registry.