1780648220 NPI number — STEPHEN TANNENBAUM M.D.

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1780648220 NPI number — STEPHEN TANNENBAUM M.D.

Employer Identification Number (EIN):

Provider Organization Name:

Provider Last Name:

TANNENBAUM

Provider First Name:

STEPHEN

Provider Middle Name:

Provider Name Prefix Text:

Provider Name Suffix Text:

Provider Credential Text:

M.D.

Provider Gender Code:

M

Provider Other Organization Name:

Provider Other Organization Name Type Code:

Provider Other Last Name:

Provider Other First Name:

Provider Other Middle Name:

Provider Other Name Prefix Text:

Provider Other Name Suffix Text:

Provider Other Credential Text:

Provider Other Last Name Type Code:

NPI Number:

1780648220

Entity Type Code:

Individual

Replacement NPI:

Last Update Date:

05/02/2016

NPI Deactivation Reason Code:

NPI Deactivation Date:

NPI Reactivation Date:

Provider First Line Business Mailing Address:

2234 COLONIAL BLVD

Provider Second Line Business Mailing Address:

MANAGED CARE DEPT

Provider Business Mailing Address City Name:

FORT MYERS

Provider Business Mailing Address State Name:

FL

Provider Business Mailing Address Postal Code:

33907-1412

Provider Business Mailing Address Country Code:

US

Provider Business Mailing Address Telephone Number:

239-931-7342

Provider Business Mailing Address Fax Number:

239-931-7385

Provider First Line Business Practice Location Address:

21150 BISCAYNE BLVD

Provider Second Line Business Practice Location Address:

404

Provider Business Practice Location Address City Name:

AVENTURA

Provider Business Practice Location Address State Name:

FL

Provider Business Practice Location Address Postal Code:

33180-1226

Provider Business Practice Location Address Country Code:

US

Provider Business Practice Location Address Telephone Number:

305-466-9111

Provider Business Practice Location Address Fax Number:

305-466-9127

Provider Enumeration Date:

04/13/2006

Authorized Official Last Name:

Authorized Official First Name:

Authorized Official Middle Name:

Authorized Official Title or Position:

Authorized Official Telephone Number:

• Taxonomy code: 174400000X , with the licence number:  : ME80333 , registered in the state of FL ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
• Taxonomy code: 208800000X , with the licence number: ME0080333 , registered in the state of FL ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

• Identifier: P00614895 . This is a "RR MEDICARE" identifier , issued by the state of ( FL ) . This identifiers is of the category "OTHER".
• Identifier: 03283 . This is a "BCBS FL" identifier , issued by the state of ( FL ) . This identifiers is of the category "OTHER".
• Identifier: 1193485 . This is a "WELLCARE" identifier , issued by the state of ( FL ) . This identifiers is of the category "OTHER".
• Identifier: 0486638 . This is a "CIGNA" identifier , issued by the state of ( FL ) . This identifiers is of the category "OTHER".
• Identifier: 260392600 , issued by the state of ( FL ) . This identifiers is of the category "MEDICAID".
• Identifier: P0003168 . This is a "FLORIDA HEALTHCARE PLUS" identifier , issued by the state of ( FL ) . This identifiers is of the category "OTHER".
• Identifier: 10719 . This is a "DIMENSION HEALTH PLAN" identifier , issued by the state of ( FL ) . This identifiers is of the category "OTHER".
• Identifier: 7755456 . This is a "AETNA PROVIDER #" identifier , issued by the state of ( FL ) . This identifiers is of the category "OTHER".
• Identifier: 1072583 . This is a "CAREPLUS" identifier , issued by the state of ( FL ) . This identifiers is of the category "OTHER".
• Identifier: P01720866 . This is a "SIMPLY HEALTHCARE" identifier , issued by the state of ( FL ) . This identifiers is of the category "OTHER".