Provider Demographics
NPI:1992845598
Name:TANNENBAUM, MICHAEL G (DC)
Entity Type:Individual
Prefix:
First Name:MICHAEL
Middle Name:G
Last Name:TANNENBAUM
Suffix:
Gender:M
Credentials:DC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4059 STONE SCHOOL RD
Mailing Address - Street 2:
Mailing Address - City:ANN ARBOR
Mailing Address - State:MI
Mailing Address - Zip Code:48108-9723
Mailing Address - Country:US
Mailing Address - Phone:734-929-0444
Mailing Address - Fax:734-929-0350
Practice Address - Street 1:4059 STONE SCHOOL RD
Practice Address - Street 2:
Practice Address - City:ANN ARBOR
Practice Address - State:MI
Practice Address - Zip Code:48108-9723
Practice Address - Country:US
Practice Address - Phone:734-929-0444
Practice Address - Fax:734-929-0350
Is Sole Proprietor?:No
Enumeration Date:2007-02-06
Last Update Date:2008-04-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI2301008615111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes111N00000XChiropractic ProvidersChiropractor
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI4755140Medicaid
MINC011916OtherM-CARE
MI0P41720Medicare UPIN
MIP41720001Medicare PIN