Provider Demographics
NPI:1649200767
Name:LAUTENBACH, EBBING (MD)
Entity Type:Individual
Prefix:
First Name:EBBING
Middle Name:
Last Name:LAUTENBACH
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 1:3400 SPRUCE STREET
Mailing Address - Street 2:
Mailing Address - City:PHILADELPHIA
Mailing Address - State:PA
Mailing Address - Zip Code:19104
Mailing Address - Country:US
Mailing Address - Phone:215-662-6932
Mailing Address - Fax:
Practice Address - Street 1:3400 SPRUCE STREET
Practice Address - Street 2:
Practice Address - City:PHILADELPHIA
Practice Address - State:PA
Practice Address - Zip Code:19104
Practice Address - Country:US
Practice Address - Phone:215-662-6932
Practice Address - Fax:215-662-7899
Is Sole Proprietor?:No
Enumeration Date:2006-07-04
Last Update Date:2013-01-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PAMD056932L207RI0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RI0200XAllopathic & Osteopathic PhysiciansInternal MedicineInfectious Disease
Provider Identifiers
StateIdentifier IDID TypeIssuer
PA0017525470001Medicaid
PA0017525470001Medicaid
G93789Medicare UPIN