Provider Demographics
NPI:1245402353
Name:TENNANT, PAUL ALBERT (MD)
Entity Type:Individual
Prefix:
First Name:PAUL
Middle Name:ALBERT
Last Name:TENNANT
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 776347
Mailing Address - Street 2:
Mailing Address - City:CHICAGO
Mailing Address - State:IL
Mailing Address - Zip Code:60677-6347
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:502-272-5339
Practice Address - Street 1:676 S FLOYD ST
Practice Address - Street 2:
Practice Address - City:LOUISVILLE
Practice Address - State:KY
Practice Address - Zip Code:40202-1840
Practice Address - Country:US
Practice Address - Phone:502-629-2500
Practice Address - Fax:502-629-4445
Is Sole Proprietor?:No
Enumeration Date:2008-03-28
Last Update Date:2023-02-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL036159391207Y00000X
IN01087491A207Y00000X
SC35846207Y00000X
KY47338207Y00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Y00000XAllopathic & Osteopathic PhysiciansOtolaryngology
Provider Identifiers
StateIdentifier IDID TypeIssuer
IN201231030Medicaid
KY7100136930Medicaid
KY7100136930Medicaid