Provider Demographics
NPI:1326136730
Name:PENDLETON, TANIS S (MD,PHD)
Entity Type:Individual
Prefix:
First Name:TANIS
Middle Name:S
Last Name:PENDLETON
Suffix:
Gender:F
Credentials:MD,PHD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:100 HOSPITAL RD
Mailing Address - Street 2:
Mailing Address - City:BROOKVILLE
Mailing Address - State:PA
Mailing Address - Zip Code:15825-1367
Mailing Address - Country:US
Mailing Address - Phone:814-849-1876
Mailing Address - Fax:
Practice Address - Street 1:100 HOSPITAL RD
Practice Address - Street 2:
Practice Address - City:BROOKVILLE
Practice Address - State:PA
Practice Address - Zip Code:15825-1367
Practice Address - Country:US
Practice Address - Phone:814-849-1876
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2006-10-11
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PAMD429688207L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207L00000XAllopathic & Osteopathic PhysiciansAnesthesiology
Provider Identifiers
StateIdentifier IDID TypeIssuer
MS08775798Medicaid
MS08775798Medicaid