1265432298 NPI number — ALLAN HENRY TISSENBAUM MD

Table of content: ALLAN HENRY TISSENBAUM MD (NPI 1265432298)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1265432298 NPI number — ALLAN HENRY TISSENBAUM MD

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
TISSENBAUM
Provider First Name:
ALLAN
Provider Middle Name:
HENRY
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
MD
Provider Gender Code:
M

Provider's Other Name Information

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 Information

NPI Number:
1265432298
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
11/02/2021
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
800 PLAZA DR STE 400
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
ROSTRAVER TWP
Provider Business Mailing Address State Name:
PA
Provider Business Mailing Address Postal Code:
15012-4019
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
724-379-5802
Provider Business Mailing Address Fax Number:

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
800 PLAZA DRIVE
Provider Second Line Business Practice Location Address:
SUITE 400
Provider Business Practice Location Address City Name:
BELLE VERNON
Provider Business Practice Location Address State Name:
PA
Provider Business Practice Location Address Postal Code:
15012
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
724-379-5816
Provider Business Practice Location Address Fax Number:
724-379-5874
Provider Enumeration Date:
08/01/2005

Additional Information

Authorized Official

Authorized Official Last Name:
Authorized Official First Name:
Authorized Official Middle Name:
Authorized Official Title or Position:
Authorized Official Telephone Number:

Provider Taxonomy Codes

  • Taxonomy code: 207X00000X , with the licence number:  MD051744L , registered in the state of PA ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)

  • Identifier: 0016061820003 , issued by the state of ( PA ) . This identifiers is of the category "MEDICAID".




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