Basic Information
| Provider Information | |||||||||
| NPI: | 1477516516 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | TAM | ||||||||
| FirstName: | JENNIFER | ||||||||
| MiddleName: | L | ||||||||
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| Credential: | M.D. | ||||||||
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| Mailing Information | |||||||||
| Address1: | 5525 RESEARCH PARK DR FL 4 | ||||||||
| Address2: | |||||||||
| City: | BALTIMORE | ||||||||
| State: | MD | ||||||||
| PostalCode: | 212284873 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7815347100 | ||||||||
| FaxNumber: | 7815347358 | ||||||||
| Practice Location | |||||||||
| Address1: | 300 LINDEN PONDS WAY | ||||||||
| Address2: | |||||||||
| City: | HINGHAM | ||||||||
| State: | MA | ||||||||
| PostalCode: | 020433769 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7815347100 | ||||||||
| FaxNumber: | 7815347358 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 04/10/2006 | ||||||||
| LastUpdateDate: | 12/09/2014 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | Y | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207R00000X | 154342 | MA | N | Allopathic & Osteopathic Physicians | Internal Medicine | 207RG0300X | 154342 | MA | Y | Allopathic & Osteopathic Physicians | Internal Medicine | Geriatric Medicine |
ID Information
| ID | Type | State | Issuer | Description | 1477516516 | 01 | BCBS | OTHER | 409588 | 01 | TRICARE NORTH | OTHER | AA48828 | 01 | HARVARD PILGRIM | OTHER | 04-09588 | 01 | EVERCARE | OTHER | 3192245 | 05 | MA | MEDICAID |