1508871310 NPI number — TATYANA TENENBOYM CRNA

Table of content: TATYANA TENENBOYM CRNA (NPI 1508871310)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1508871310 NPI number — TATYANA TENENBOYM CRNA

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
TENENBOYM
Provider First Name:
TATYANA
Provider Middle Name:
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
CRNA
Provider Gender Code:
F

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:
1508871310
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
11/14/2011
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
P.O. BOX 372
Provider Second Line Business Mailing Address:
C/O MA ANESTHESIA CORP
Provider Business Mailing Address City Name:
STOUGHTON
Provider Business Mailing Address State Name:
MA
Provider Business Mailing Address Postal Code:
02072-0372
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
781-341-3966
Provider Business Mailing Address Fax Number:
781-341-8269

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
50 STANIFORD STREET
Provider Second Line Business Practice Location Address:
C/O MA ANESTHESIA CORP
Provider Business Practice Location Address City Name:
BOSTON
Provider Business Practice Location Address State Name:
MA
Provider Business Practice Location Address Postal Code:
02114
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
248-423-5100
Provider Business Practice Location Address Fax Number:
Provider Enumeration Date:
07/30/2006

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: 367500000X , with the licence number:  4704205247 , registered in the state of MI ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 367500000X , with the licence number: 2265689 , registered in the state of MA ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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

  • Identifier: TT205247 . This is a "BLUE CROSS OF MI" identifier , issued by the state of ( MI ) . This identifiers is of the category "OTHER".
  • Identifier: 104783761 , issued by the state of ( MI ) . This identifiers is of the category "MEDICAID".
  • Identifier: 116297300 . This is a "Florida Medicaid Provider ID" identifier , issued by the state of ( FL ) . This identifiers is of the category "MEDICAID".




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