Healthcare Provider Details

I. General information

NPI: 1982928560
Provider Name (Legal Business Name): MARC EDWARD TENNENBAUM D.O.
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 03/25/2010
Last Update Date: 03/25/2010
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3900 N POWERLINE RD
POMPANO BEACH FL
33073-3013
US

IV. Provider business mailing address

3535 S OCEAN DR APT 1905
HOLLYWOOD FL
33019-2898
US

V. Phone/Fax

Practice location:
  • Phone: 954-973-4485
  • Fax:
Mailing address:
  • Phone: 305-747-3179
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License NumberOS8355
License Number StateFL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: