NPIMap

Individual provider Active NPI

Tisha Joerla Mirasol Tan, M.D.

  • Nephrology Physician
  • Crystal Lake, IL
National Provider Identifier
1881959872
Registry record updated Sep 15, 2022
On this page

Key facts

NPPES NPI Registry
Primary specialty
Nephrology PhysicianTaxonomy code 207RN0300X
License
036137011 Issued in IL
Practice address
442 N Il Route 31
Crystal Lake, IL 60012-3709
Phone
(224) 238-3211
Fax
(224) 535-8215
NPI assigned
Jul 6, 2012
Sex
Female
Sole proprietor
No

NPPES NPI Registry

Updated by the provider on Sep 15, 2022

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

Specialties & licenses 1

Specialty (taxonomy)CodeLicenseStatePrimary
Nephrology Physician 207RN0300X 036137011 IL Primary

Addresses

Primary practice location

442 N Il Route 31
Crystal Lake, IL 60012-3709

Mailing address

PO Box 3877
Joliet, IL 60434-3877
Phone (815) 741-6830

Other practice location 1

1670 Capital St Unit 900
Elgin, IL 60124-7837
Phone (847) 285-1908

Electronic endpoints 2

TypeEndpointUseAffiliation
FHIR URL https://epicfhir.aurora.org/FHIR/MYAURORA/api/FHIR/DSTU2/
Direct Messaging Address ttan234466@direct.myadvocateaurora.org Direct

Medicare participation

Medicare enrollment files
Medicare fee-for-service enrollment
Enrolled in IL
Eligible to order & refer
  • Part B services
  • Medical equipment
  • Home health
  • Power mobility devices
  • Hospice
Green means eligible to order or refer.

Enrollment records 1

Enrollment IDStateProvider typePAC IDDetails
I20170322000482 IL Practitioner - Nephrology 5294037958 Reassigns benefits to 1 organization

Care Compare profile

Medicare Care Compare
Specialty
Nephrology
Education
Other, 2008
Medicare assignment
Accepts the Medicare-approved amount as payment in full
Telehealth
Offers telehealth services
Group practices
Kidney Care Center Elgin LLCGroup PAC ID 2769634252, 8 clinicians

Practice addresses (Care Compare)

1670 Capital St
Suite 900
Elgin, IL 60124-8198
Phone (224) 238-3211

Hospital & facility affiliations

National Provider Directory

National Provider Directory
Medicare enrollment (NPD)
Enrolled
Credentials
Doctor of Medicine

State licenses

LicenseStateTypeSpecialty
036137011ILMDNephrology Physician

Practice roles

OrganizationSpecialtyStatusNew patients
Kidney Care Center Elgin LLC Nephrology CurrentSince Dec 1, 2017 Accepting new patients
Dialysis Care Center Elgin LLC PastSince Jun 13, 2018 Accepting new patients

Locations

442 N Il Route 31
Crystal Lake, IL 60012
Phone (224) 238-3211

1670 Capital St
Ste 900
Elgin, IL 60124
Phone (224) 214-1943

10370 Haligus Rd
Ste 115
Huntley, IL 60142
Phone (815) 479-8166

1843 W Irving Park Rd
Schaumburg, IL 60193
Phone (847) 285-1908

Organizations & group practices 2

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.

Hospital & facility affiliations 10

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": "1341532800000",
    "enumeration_type": "NPI-1",
    "last_updated_epoch": "1663200000000",
    "number": "1881959872",
    "addresses": [
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "MAILING",
            "address_type": "DOM",
            "address_1": "PO BOX 3877",
            "city": "JOLIET",
            "state": "IL",
            "postal_code": "604343877",
            "telephone_number": "815-741-6830",
            "fax_number": "815-741-6832"
        },
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "LOCATION",
            "address_type": "DOM",
            "address_1": "442 N IL ROUTE 31",
            "city": "CRYSTAL LAKE",
            "state": "IL",
            "postal_code": "600123709",
            "telephone_number": "224-238-3211",
            "fax_number": "224-535-8215"
        }
    ],
    "practiceLocations": [
        {
            "address_1": "1670 Capital St Unit 900",
            "address_purpose": "LOCATION",
            "city": "Elgin",
            "state": "IL",
            "postal_code": "601247837",
            "country_code": "US",
            "telephone_number": "847-285-1908",
            "country_name": "United States",
            "address_type": "DOM"
        }
    ],
    "basic": {
        "last_name": "TAN",
        "first_name": "TISHA JOERLA",
        "middle_name": "MIRASOL",
        "credential": "M.D.",
        "sole_proprietor": "NO",
        "sex": "F",
        "enumeration_date": "2012-07-06",
        "last_updated": "2022-09-15",
        "certification_date": "2022-09-15",
        "status": "A"
    },
    "taxonomies": [
        {
            "code": "207RN0300X",
            "taxonomy_group": "",
            "desc": "Internal Medicine, Nephrology",
            "state": "IL",
            "license": "036137011",
            "primary": true
        }
    ],
    "identifiers": [],
    "endpoints": [
        {
            "endpointType": "FHIR",
            "endpointTypeDescription": "FHIR URL",
            "endpoint": "https://epicfhir.aurora.org/FHIR/MYAURORA/api/FHIR/DSTU2/",
            "affiliation": "N",
            "address_1": "442 N Il Route 31",
            "city": "Crystal Lake",
            "state": "IL",
            "country_code": "US",
            "postal_code": "600123709",
            "country_name": "United States",
            "address_type": "DOM"
        },
        {
            "endpointType": "DIRECT",
            "endpointTypeDescription": "Direct Messaging Address",
            "endpoint": "ttan234466@direct.myadvocateaurora.org",
            "affiliation": "N",
            "use": "DIRECT",
            "useDescription": "Direct",
            "address_1": "442 N Il Route 31",
            "city": "Crystal Lake",
            "state": "IL",
            "country_code": "US",
            "postal_code": "600123709",
            "country_name": "United States",
            "address_type": "DOM"
        }
    ],
    "other_names": []
}

Other providers in Crystal Lake, IL

Sources for this page

Verify at the official NPI Registry.