Basic Information
| Provider Information | |||||||||
| NPI: | 1538112057 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | TENAGLIA | ||||||||
| FirstName: | NICHOLAS | ||||||||
| MiddleName: | C | ||||||||
| NamePrefix: | DR. | ||||||||
| NameSuffix: | |||||||||
| Credential: | M.D. | ||||||||
| OtherOrganizationName: | |||||||||
| OtherOrganizationType: | |||||||||
| OtherLastName: | |||||||||
| OtherFirstName: | |||||||||
| OtherMiddleName: | |||||||||
| OtherNamePrefix: | |||||||||
| OtherNameSuffix: | |||||||||
| OtherCredential: | |||||||||
| OtherLastNameType: | |||||||||
| Mailing Information | |||||||||
| Address1: | 769 GERMANTOWN PIKE | ||||||||
| Address2: | |||||||||
| City: | LAFAYETTE HILL | ||||||||
| State: | PA | ||||||||
| PostalCode: | 194441620 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6109413921 | ||||||||
| FaxNumber: | 6109413391 | ||||||||
| Practice Location | |||||||||
| Address1: | 521 PLYMOUTH RD | ||||||||
| Address2: | SUITE 106 | ||||||||
| City: | PLYMOUTH MEETING | ||||||||
| State: | PA | ||||||||
| PostalCode: | 194621638 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6109413921 | ||||||||
| FaxNumber: | 6109413391 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 05/18/2006 | ||||||||
| LastUpdateDate: | 07/24/2008 | ||||||||
| NPIDeactivationReasonCode: | |||||||||
| NPIDeactivationDate: | |||||||||
| NPIReactivationDate: | |||||||||
| ProviderGenderCode: | M | ||||||||
| AuthorizedOfficialLastName: | |||||||||
| AuthorizedOfficialFirstName: | |||||||||
| AuthorizedOfficialMiddleName: | |||||||||
| AuthorizedOfficialTitleorPosition: | |||||||||
| AuthorizedOfficialTelephone: | |||||||||
| IsSoleProprietor: | Y | ||||||||
| IsOrganizationSubpart: | |||||||||
| ParentOrganizationLBN: | |||||||||
| AuthorizedOfficialNamePrefix: | |||||||||
| AuthorizedOfficialNameSuffix: | |||||||||
| AuthorizedOfficialCredential: | |||||||||
| NPICertificationDate: | |||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 2084P0800X | MD008185E | PA | Y | Allopathic & Osteopathic Physicians | Psychiatry & Neurology | Psychiatry |
ID Information
| ID | Type | State | Issuer | Description | 047574 | 01 | PA | TRICARE | OTHER | 1162670 | 01 | PA | HIGHMARK BLUE SHIELD | OTHER | 4536585 | 01 | PA | AETNA | OTHER | 0008946730005 | 05 | PA | MEDICAID |