MEDICARE: NICHOLAS HENRY TANNENBAUM

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	207PE0004X	Emergency Medical Services (Emergency Medicine) Physician	12918	GA
2	207PE0004X	Emergency Medical Services (Emergency Medicine) Physician	2024-01464	NC

General Provider Information

NPI Number	:	1013584382
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	NICHOLAS HENRY TANNENBAUM

Provider Business Mailing Address
First Line	:	2817 ROCK MERRITT AVE
Second Line	:
City	:	FORT BRAGG
State	:	NC
Zip	:	28310-0001
Country	:	US
Telephone Number	:
Fax Number	:

Provider Business Practice Location Address
First Line	:	2817 ROCK MERRITT AVE
Second Line	:
City	:	FORT BRAGG
State	:	NC
Zip	:	28310-0004
Country	:	US
Telephone Number	:	910-907-8922
Fax Number	:	910-907-6069

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	06/07/2021
Last Update Date	:	01/30/2026

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