Provider Demographics
NPI: | 1417072596 |
---|---|
Name: | EISENBERG, TARA RAQUEL (MD) |
Entity Type: | Individual |
Prefix: | |
First Name: | TARA |
Middle Name: | RAQUEL |
Last Name: | EISENBERG |
Suffix: | |
Gender: | F |
Credentials: | MD |
Other - Prefix: | |
Other - First Name: | TARA |
Other - Middle Name: | RAQUEL |
Other - Last Name: | HERZBERG |
Other - Suffix: | |
Other - Last Name Type: | Former Name |
Other - Credentials: | MD |
Mailing Address - Street 1: | 111 S 11TH ST |
Mailing Address - Street 2: | SUITE 3390 |
Mailing Address - City: | PHILADELPHIA |
Mailing Address - State: | PA |
Mailing Address - Zip Code: | 19107-4824 |
Mailing Address - Country: | US |
Mailing Address - Phone: | 215-955-6226 |
Mailing Address - Fax: | 215-923-1562 |
Practice Address - Street 1: | 111 S 11TH ST |
Practice Address - Street 2: | SUITE 3390 |
Practice Address - City: | PHILADELPHIA |
Practice Address - State: | PA |
Practice Address - Zip Code: | 19107-4824 |
Practice Address - Country: | US |
Practice Address - Phone: | 215-955-6226 |
Practice Address - Fax: | 215-923-1562 |
Is Sole Proprietor?: | No |
Enumeration Date: | 2007-03-20 |
Last Update Date: | 2010-06-10 |
Deactivation Date: | |
Deactivation Code: | |
Reactivation Date: |
Provider Licenses
State | License ID | Taxonomies |
---|---|---|
PA | MD437294 | 2085R0202X |
Provider Taxonomies
Primary? | Code | Type | Classification | Specialization |
---|---|---|---|---|
Yes | 2085R0202X | Allopathic & Osteopathic Physicians | Radiology | Diagnostic Radiology |
Provider Identifiers
State | Identifier ID | ID Type | Issuer |
---|---|---|---|
NC | 145XU | Other | BCBSNC |
PA | 102337804 | Medicaid | |
NC | 5907571 | Medicaid | |
PA | 102337804 | Medicaid | |
NC | 2069081A | Medicare PIN |