Provider Demographics
NPI:1265782296
Name:RUSS TANNENBAUM DC PA
Entity type:Organization
Organization Name:RUSS TANNENBAUM DC PA
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:BILLER
Authorized Official - Prefix:MS
Authorized Official - First Name:MARY
Authorized Official - Middle Name:
Authorized Official - Last Name:HAWKS
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:954-993-4058
Mailing Address - Street 1:5800 COLONIAL DRIVE
Mailing Address - Street 2:STE 305
Mailing Address - City:MARGATE
Mailing Address - State:FL
Mailing Address - Zip Code:33063
Mailing Address - Country:US
Mailing Address - Phone:954-993-4058
Mailing Address - Fax:954-916-5198
Practice Address - Street 1:5800 COLONIAL DR
Practice Address - Street 2:STE 305
Practice Address - City:MARGATE
Practice Address - State:FL
Practice Address - Zip Code:33063-5682
Practice Address - Country:US
Practice Address - Phone:954-993-4058
Practice Address - Fax:954-916-5198
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2012-09-18
Last Update Date:2012-09-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLCH4086111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes111N00000XChiropractic ProvidersChiropractorGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL88856OtherBLUE CROSS FLORIDA
FL88856Medicare PIN