Provider Demographics
NPI:1982649315
Name:TANNENBAUM, ERIC S (MD)
Entity Type:Individual
Prefix:
First Name:ERIC
Middle Name:S
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 1:15225 SHADY GROVE RD
Mailing Address - Street 2:SUITE 201
Mailing Address - City:ROCKVILLE
Mailing Address - State:MD
Mailing Address - Zip Code:20850-3254
Mailing Address - Country:US
Mailing Address - Phone:301-670-3000
Mailing Address - Fax:301-924-0186
Practice Address - Street 1:15225 SHADY GROVE RD
Practice Address - Street 2:SUITE 201
Practice Address - City:ROCKVILLE
Practice Address - State:MD
Practice Address - Zip Code:20850-3254
Practice Address - Country:US
Practice Address - Phone:301-670-3000
Practice Address - Fax:301-924-0186
Is Sole Proprietor?:No
Enumeration Date:2006-06-19
Last Update Date:2013-04-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MDD0027886207RC0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RC0000XAllopathic & Osteopathic PhysiciansInternal MedicineCardiovascular Disease
Provider Identifiers
StateIdentifier IDID TypeIssuer
MD383001200Medicaid
MD016713C83OtherMEDICARE PTAN
MD383001200Medicaid
MD016713C83OtherMEDICARE PTAN
MD197150L41Medicare PIN