Provider Demographics
NPI:1922000116
Name:TANNENBAUM, JORDAN M (MD)
Entity Type:Individual
Prefix:DR
First Name:JORDAN
Middle Name:M
Last Name:TANNENBAUM
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
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Other - Credentials:
Mailing Address - Street 1:1 FOX CARE DR
Mailing Address - Street 2:STE 213
Mailing Address - City:ONEONTA
Mailing Address - State:NY
Mailing Address - Zip Code:13820-2086
Mailing Address - Country:US
Mailing Address - Phone:607-432-5600
Mailing Address - Fax:607-431-5275
Practice Address - Street 1:1 FOX CARE DR
Practice Address - Street 2:STE 213
Practice Address - City:ONEONTA
Practice Address - State:NY
Practice Address - Zip Code:13820-2086
Practice Address - Country:US
Practice Address - Phone:607-432-5600
Practice Address - Fax:607-431-5275
Is Sole Proprietor?:No
Enumeration Date:2005-06-01
Last Update Date:2010-06-29
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
NY149788208000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208000000XAllopathic & Osteopathic PhysiciansPediatrics
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY00279098Medicaid
NY002892901OtherBLUE CROSS BLUE SHIELD
NY00279098Medicaid