Provider Demographics
NPI:1912902933
Name:TANENBAUM, SETH R (MD)
Entity Type:Individual
Prefix:DR
First Name:SETH
Middle Name:R
Last Name:TANENBAUM
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
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Other - Last Name:
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Other - Credentials:
Mailing Address - Street 1:2800 N SHERIDAN RD
Mailing Address - Street 2:STE 400
Mailing Address - City:CHICAGO
Mailing Address - State:IL
Mailing Address - Zip Code:60657-6157
Mailing Address - Country:US
Mailing Address - Phone:773-871-7384
Mailing Address - Fax:773-377-1766
Practice Address - Street 1:2800 N SHERIDAN RD
Practice Address - Street 2:STE 400
Practice Address - City:CHICAGO
Practice Address - State:IL
Practice Address - Zip Code:60657-6157
Practice Address - Country:US
Practice Address - Phone:773-871-7384
Practice Address - Fax:773-377-1766
Is Sole Proprietor?:Yes
Enumeration Date:2005-06-16
Last Update Date:2010-02-15
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
IL036-069434207RC0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RC0000XAllopathic & Osteopathic PhysiciansInternal MedicineCardiovascular Disease
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL036069434Medicaid
340530Medicare ID - Type Unspecified
C43661Medicare UPIN