Provider Demographics
NPI:1255619854
Name:BAUM, TAMARA MARIE (MD)
Entity type:Individual
Prefix:DR
First Name:TAMARA
Middle Name:MARIE
Last Name:BAUM
Suffix:
Gender:F
Credentials:MD
Other - Prefix:DR
Other - First Name:TAMARA
Other - Middle Name:MARIE
Other - Last Name:JETTE
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:MD
Mailing Address - Street 1:110 LAMB TAVERN LN
Mailing Address - Street 2:
Mailing Address - City:GLENMOORE
Mailing Address - State:PA
Mailing Address - Zip Code:19343-1818
Mailing Address - Country:US
Mailing Address - Phone:267-567-2349
Mailing Address - Fax:
Practice Address - Street 1:555 N DUKE ST
Practice Address - Street 2:
Practice Address - City:LANCASTER
Practice Address - State:PA
Practice Address - Zip Code:17602-2250
Practice Address - Country:US
Practice Address - Phone:717-544-4900
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2011-07-30
Last Update Date:2023-12-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PAMT200298207T00000X
PAMD453089207T00000X, 2085R0202X, 2085R0204X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2085R0204XAllopathic & Osteopathic PhysiciansRadiologyVascular & Interventional Radiology
No207T00000XAllopathic & Osteopathic PhysiciansNeurological Surgery
No2085R0202XAllopathic & Osteopathic PhysiciansRadiologyDiagnostic Radiology
Provider Identifiers
StateIdentifier IDID TypeIssuer
PA103514841-0003Medicaid