Provider Demographics
NPI:1295748994
Name:TANNENBAUM, SCOTT DAVID (MD)
Entity type:Individual
Prefix:
First Name:SCOTT
Middle Name:DAVID
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:PO BOX 267515
Mailing Address - Street 2:
Mailing Address - City:WESTON
Mailing Address - State:FL
Mailing Address - Zip Code:33326
Mailing Address - Country:US
Mailing Address - Phone:954-746-1338
Mailing Address - Fax:954-746-1331
Practice Address - Street 1:4399 NOB HILL ROAD
Practice Address - Street 2:
Practice Address - City:SUNRISE
Practice Address - State:FL
Practice Address - Zip Code:33351
Practice Address - Country:US
Practice Address - Phone:954-746-1338
Practice Address - Fax:954-746-1331
Is Sole Proprietor?:No
Enumeration Date:2006-08-14
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLME57381208100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208100000XAllopathic & Osteopathic PhysiciansPhysical Medicine & Rehabilitation
Provider Identifiers
StateIdentifier IDID TypeIssuer
FLME57301OtherSTATE LICENSE
E63457Medicare UPIN
10779Medicare ID - Type Unspecified