Healthcare Provider Details

I. General information

NPI: 1528030004
Provider Name (Legal Business Name): LEE ERIC TANNENBAUM M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 02/07/2006
Last Update Date: 05/22/2008
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2012 S TOLLGATE RD STE 106
BEL AIR MD
21015-5900
US

IV. Provider business mailing address

2012 S TOLLGATE RD STE 106
BEL AIR MD
21015-5900
US

V. Phone/Fax

Practice location:
  • Phone: 410-569-9429
  • Fax: 410-569-9423
Mailing address:
  • Phone: 410-569-9429
  • Fax: 410-569-9423

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207QA0401X
TaxonomyAddiction Medicine (Family Medicine) Physician
License NumberD39763
License Number StateMD
# 2
Primary TaxonomyN
Taxonomy Code207QA0505X
TaxonomyAdult Medicine Physician
License NumberD39763
License Number StateMD

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: