Provider Demographics
NPI:1386817831
Name:TANNOUS, NICHOLAS J (MD)
Entity Type:Individual
Prefix:DR
First Name:NICHOLAS
Middle Name:J
Last Name:TANNOUS
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 1:2 PARK CENTER CT STE 200
Mailing Address - Street 2:
Mailing Address - City:OWINGS MILLS
Mailing Address - State:MD
Mailing Address - Zip Code:21117-4221
Mailing Address - Country:US
Mailing Address - Phone:443-693-7246
Mailing Address - Fax:
Practice Address - Street 1:19851 OBSERVATION DR STE 360
Practice Address - Street 2:
Practice Address - City:GERMANTOWN
Practice Address - State:MD
Practice Address - Zip Code:20876-4141
Practice Address - Country:US
Practice Address - Phone:443-693-7246
Practice Address - Fax:301-337-6478
Is Sole Proprietor?:No
Enumeration Date:2008-04-04
Last Update Date:2018-11-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO2012005502208100000X, 2081P2900X
NV154772081P2900X
VA1012638582081P2900X
MDD00846552081P2900X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2081P2900XAllopathic & Osteopathic PhysiciansPhysical Medicine & RehabilitationPain Medicine
No208100000XAllopathic & Osteopathic PhysiciansPhysical Medicine & Rehabilitation
Provider Identifiers
StateIdentifier IDID TypeIssuer
12355682OtherCAQH
MO000000767742OtherBCBSMO
NV1386817831Medicaid
NV1386817831Medicaid