Provider Demographics
NPI:1184601627
Name:TANENBAUM, JUDITH ANN (PAC)
Entity type:Individual
Prefix:
First Name:JUDITH
Middle Name:ANN
Last Name:TANENBAUM
Suffix:
Gender:F
Credentials:PAC
Other - Prefix:
Other - First Name:JUDITH
Other - Middle Name:ANN
Other - Last Name:LEVINE
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:
Mailing Address - Street 1:623 UNRUH AVE
Mailing Address - Street 2:2ND FL
Mailing Address - City:PHILA
Mailing Address - State:PA
Mailing Address - Zip Code:19111
Mailing Address - Country:US
Mailing Address - Phone:215-214-1094
Mailing Address - Fax:215-214-1098
Practice Address - Street 1:2100 W GIRARD AVE
Practice Address - Street 2:
Practice Address - City:PHILA
Practice Address - State:PA
Practice Address - Zip Code:19130
Practice Address - Country:US
Practice Address - Phone:215-214-1094
Practice Address - Fax:215-214-1098
Is Sole Proprietor?:Not Answered
Enumeration Date:2005-12-27
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PAMA002088L363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
S50947Medicare UPIN
PATAO34164Medicare ID - Type Unspecified