Provider Demographics
NPI:1629022744
Name:TANENBAUM, MARC A (MD)
Entity Type:Individual
Prefix:
First Name:MARC
Middle Name:A
Last Name:TANENBAUM
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:MARC
Other - Middle Name:ALAN
Other - Last Name:TANENBAUM
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:MD
Mailing Address - Street 1:6300 POWERS FERRY ROAD
Mailing Address - Street 2:SUITE 600, POB #202
Mailing Address - City:ATLANTA
Mailing Address - State:GA
Mailing Address - Zip Code:30339-2961
Mailing Address - Country:US
Mailing Address - Phone:404-654-0426
Mailing Address - Fax:678-806-0900
Practice Address - Street 1:6300 POWERS FERRY ROAD
Practice Address - Street 2:SUITE 600, POB 200
Practice Address - City:ATLANTA
Practice Address - State:GA
Practice Address - Zip Code:30339-2961
Practice Address - Country:US
Practice Address - Phone:404-654-0426
Practice Address - Fax:678-806-0900
Is Sole Proprietor?:Yes
Enumeration Date:2006-05-22
Last Update Date:2010-04-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA019429208000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208000000XAllopathic & Osteopathic PhysiciansPediatrics