Provider Demographics
NPI:1538112057
Name:TENAGLIA, NICHOLAS C (MD)
Entity Type:Individual
Prefix:DR
First Name:NICHOLAS
Middle Name:C
Last Name:TENAGLIA
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 1:769 GERMANTOWN PIKE
Mailing Address - Street 2:
Mailing Address - City:LAFAYETTE HILL
Mailing Address - State:PA
Mailing Address - Zip Code:19444-1620
Mailing Address - Country:US
Mailing Address - Phone:610-941-3921
Mailing Address - Fax:610-941-3391
Practice Address - Street 1:521 PLYMOUTH RD
Practice Address - Street 2:SUITE 106
Practice Address - City:PLYMOUTH MEETING
Practice Address - State:PA
Practice Address - Zip Code:19462-1638
Practice Address - Country:US
Practice Address - Phone:610-941-3921
Practice Address - Fax:610-941-3391
Is Sole Proprietor?:Yes
Enumeration Date:2006-05-18
Last Update Date:2008-07-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PAMD008185E2084P0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2084P0800XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyPsychiatry
Provider Identifiers
StateIdentifier IDID TypeIssuer
PA047574OtherTRICARE
PA1162670OtherHIGHMARK BLUE SHIELD
PA4536585OtherAETNA
PA0008946730005Medicaid
PA4536585OtherAETNA
PA047574OtherTRICARE