MEDICARE: DR. MARK TAMBELLINI M.D.

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	207QA0505X	Adult Medicine Physician	G37599	CA

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	G37599	OTHER	CA	MEDICAL BOARD OF CALIFORNIA

General Provider Information

NPI Number	:	1902115793
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	DR. MARK TAMBELLINI M.D.

Provider Business Mailing Address
First Line	:	5021 BROWER CT
Second Line	:
City	:	GRANITE BAY
State	:	CA
Zip	:	95746-6742
Country	:	US
Telephone Number	:	916-761-9399
Fax Number	:	916-774-4360

Provider Business Practice Location Address
First Line	:	5021 BROWER CT
Second Line	:
City	:	GRANITE BAY
State	:	CA
Zip	:	95746-6742
Country	:	US
Telephone Number	:	916-761-9399
Fax Number	:	916-774-4360

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

Provider Enumeration Date	:	09/28/2010
Last Update Date	:	09/28/2010

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