Basic Information
Provider Information | |||||||||
NPI: | 1184601627 | ||||||||
EntityType: | 1 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: |   | ||||||||
LastName: | TANENBAUM | ||||||||
FirstName: | JUDITH | ||||||||
MiddleName: | ANN | ||||||||
NamePrefix: |   | ||||||||
NameSuffix: |   | ||||||||
Credential: | PAC | ||||||||
OtherOrganizationName: |   | ||||||||
OtherOrganizationType: |   | ||||||||
OtherLastName: | LEVINE | ||||||||
OtherFirstName: | JUDITH | ||||||||
OtherMiddleName: | ANN | ||||||||
OtherNamePrefix: |   | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: |   | ||||||||
OtherLastNameType: | 5 | ||||||||
Mailing Information | |||||||||
Address1: | 623 UNRUH AVE | ||||||||
Address2: | 2ND FL | ||||||||
City: | PHILA | ||||||||
State: | PA | ||||||||
PostalCode: | 19111 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 2152141094 | ||||||||
FaxNumber: | 2152141098 | ||||||||
Practice Location | |||||||||
Address1: | 2100 W GIRARD AVE | ||||||||
Address2: |   | ||||||||
City: | PHILA | ||||||||
State: | PA | ||||||||
PostalCode: | 19130 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 2152141094 | ||||||||
FaxNumber: | 2152141098 | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 12/27/2005 | ||||||||
LastUpdateDate: | 07/08/2007 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: | F | ||||||||
AuthorizedOfficialLastName: |   | ||||||||
AuthorizedOfficialFirstName: |   | ||||||||
AuthorizedOfficialMiddleName: |   | ||||||||
AuthorizedOfficialTitleorPosition: |   | ||||||||
AuthorizedOfficialTelephone: |   | ||||||||
IsSoleProprietor: | X | ||||||||
IsOrganizationSubpart: |   | ||||||||
ParentOrganizationLBN: |   | ||||||||
AuthorizedOfficialNamePrefix: |   | ||||||||
AuthorizedOfficialNameSuffix: |   | ||||||||
AuthorizedOfficialCredential: |   | ||||||||
NPICertificationDate: |   |
Taxonomy Information
Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 363A00000X | MA002088L | PA | Y |   | Physician Assistants & Advanced Practice Nursing Providers | Physician Assistant |   |
No ID Information.