Provider Demographics
NPI:1376543611
Name:TANZER, JEROME (MD)
Entity Type:Individual
Prefix:DR
First Name:JEROME
Middle Name:
Last Name:TANZER
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 1:130 MARSHALL ROAD
Mailing Address - Street 2:
Mailing Address - City:LOWELL
Mailing Address - State:MA
Mailing Address - Zip Code:01852
Mailing Address - Country:US
Mailing Address - Phone:978-671-9000
Mailing Address - Fax:
Practice Address - Street 1:130 MARSHALL ROAD
Practice Address - Street 2:
Practice Address - City:LOWELL
Practice Address - State:MA
Practice Address - Zip Code:01852
Practice Address - Country:US
Practice Address - Phone:978-671-9000
Practice Address - Fax:978-671-9149
Is Sole Proprietor?:No
Enumeration Date:2005-07-28
Last Update Date:2012-08-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MA29366207RG0300X, 207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RG0300XAllopathic & Osteopathic PhysiciansInternal MedicineGeriatric Medicine
No207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
MA0198714Medicaid
MAB48118Medicare ID - Type Unspecified
MA0198714Medicaid