Basic Information
| Provider Information | |||||||||
| NPI: | 1649346925 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | TENNEY | ||||||||
| FirstName: | SUETTA | ||||||||
| MiddleName: | |||||||||
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| Credential: | MD | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 42738 | ||||||||
| Address2: | |||||||||
| City: | TOWSON | ||||||||
| State: | MD | ||||||||
| PostalCode: | 212842738 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4104947607 | ||||||||
| FaxNumber: | 6109257387 | ||||||||
| Practice Location | |||||||||
| Address1: | GENESIS HEALTH CARE WINWARD GARDENS NURSING CENTER | ||||||||
| Address2: | 105 MECHANIC STREET | ||||||||
| City: | CAMDEN | ||||||||
| State: | ME | ||||||||
| PostalCode: | 04843 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2072364197 | ||||||||
| FaxNumber: | 2072300563 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 11/28/2006 | ||||||||
| LastUpdateDate: | 04/15/2020 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 04/15/2020 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207R00000X | MD22576 | ME | Y | Allopathic & Osteopathic Physicians | Internal Medicine | 207R00000X | 71345 | MA | N | Allopathic & Osteopathic Physicians | Internal Medicine |
ID Information
| ID | Type | State | Issuer | Description | 3002764 | 05 | MA | MEDICAID | 69626 | 01 | HARVARD PILGRAM | OTHER | 71345 | 01 | MASS LICENSE # | OTHER | BT0137326 | 01 | DEA | OTHER | 712914 | 01 | TUETS HEALTH PLAN | OTHER | 0701800 | 01 | BC BS ANTHEM | OTHER | 4978 | 01 | FALLON | OTHER | 110229385 | 01 | RAILROAD MEDICARE | OTHER |