Provider Demographics
NPI:1780648220
Name:TANNENBAUM, STEPHEN (MD)
Entity Type:Individual
Prefix:
First Name:STEPHEN
Middle Name:
Last Name:TANNENBAUM
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 1:2234 COLONIAL BLVD
Mailing Address - Street 2:MANAGED CARE DEPT
Mailing Address - City:FORT MYERS
Mailing Address - State:FL
Mailing Address - Zip Code:33907-1412
Mailing Address - Country:US
Mailing Address - Phone:239-931-7342
Mailing Address - Fax:239-931-7385
Practice Address - Street 1:21150 BISCAYNE BLVD
Practice Address - Street 2:404
Practice Address - City:AVENTURA
Practice Address - State:FL
Practice Address - Zip Code:33180-1226
Practice Address - Country:US
Practice Address - Phone:305-466-9111
Practice Address - Fax:305-466-9127
Is Sole Proprietor?:No
Enumeration Date:2006-04-13
Last Update Date:2016-05-02
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
FL: ME80333174400000X
FLME0080333208800000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208800000XAllopathic & Osteopathic PhysiciansUrology
No174400000XOther Service ProvidersSpecialist
Provider Identifiers
StateIdentifier IDID TypeIssuer
FLP00614895OtherRR MEDICARE
FL03283OtherBCBS FL
FL1193485OtherWELLCARE
FL0486638OtherCIGNA
FL260392600Medicaid
FLP0003168OtherFLORIDA HEALTHCARE PLUS
FL10719OtherDIMENSION HEALTH PLAN
FL7755456OtherAETNA PROVIDER #
FL1072583OtherCAREPLUS
FLP01720866OtherSIMPLY HEALTHCARE
FLP00614895OtherRR MEDICARE
FLE4483DMedicare PIN
FL03283OtherBCBS FL
FLE4483ZMedicare PIN