Provider Demographics
NPI:1689738437
Name:TENNANT, MICHAEL L (OD)
Entity Type:Individual
Prefix:
First Name:MICHAEL
Middle Name:L
Last Name:TENNANT
Suffix:
Gender:M
Credentials:OD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Credentials:
Mailing Address - Street 1:5455 N SHERIDAN RD
Mailing Address - Street 2:#3915
Mailing Address - City:CHICAGO
Mailing Address - State:IL
Mailing Address - Zip Code:60640-1958
Mailing Address - Country:US
Mailing Address - Phone:773-784-0916
Mailing Address - Fax:773-284-1347
Practice Address - Street 1:7601 S CICERO AVE
Practice Address - Street 2:
Practice Address - City:CHICAGO
Practice Address - State:IL
Practice Address - Zip Code:60652-1022
Practice Address - Country:US
Practice Address - Phone:773-284-4294
Practice Address - Fax:773-284-1347
Is Sole Proprietor?:No
Enumeration Date:2006-12-19
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL153586Medicare UPIN