Provider Demographics
NPI:1376618363
Name:BARTON TANENBAUM MD A MEDICAL CORPORATION
Entity Type:Organization
Organization Name:BARTON TANENBAUM MD A MEDICAL CORPORATION
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:A MEDICAL CORPORATIONPRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:BARTON
Authorized Official - Middle Name:
Authorized Official - Last Name:TANENBAUM
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:310-278-2970
Mailing Address - Street 1:1127 WILSHIRE BLVD STE 805
Mailing Address - Street 2:
Mailing Address - City:LOS ANGELES
Mailing Address - State:CA
Mailing Address - Zip Code:90017-3909
Mailing Address - Country:US
Mailing Address - Phone:213-484-9900
Mailing Address - Fax:213-484-0158
Practice Address - Street 1:1127 WILSHIRE BLVD STE 805
Practice Address - Street 2:
Practice Address - City:LOS ANGELES
Practice Address - State:CA
Practice Address - Zip Code:90017-3909
Practice Address - Country:US
Practice Address - Phone:213-484-9900
Practice Address - Fax:213-484-0158
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-11-22
Last Update Date:2019-06-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAG19250208800000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes208800000XAllopathic & Osteopathic PhysiciansUrologyGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA00G192500Medicaid
CA340018176OtherRAILROAD MEDICARE
341916018OtherRAILROAD MEDICARE
CA00G129501Medicaid
00G192500OtherBLUE SHIELD
CA005G192501OtherBLUE SHIELD
CALAB94467FMedicaid
CA005G192501OtherBLUE SHIELD
CAW20946Medicare PIN
CA340018176OtherRAILROAD MEDICARE
CALAB94467FMedicaid
CA00G129501Medicaid
CA0385570001Medicare NSC