Healthcare Provider Details

I. General information

NPI: 1831195619
Provider Name (Legal Business Name): HERBERT TISNOWER M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 06/25/2005
Last Update Date: 09/09/2022
Certification Date: 09/09/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1837 S 65TH ST
PHILADELPHIA PA
19142-1423
US

IV. Provider business mailing address

1837 S 65TH ST
PHILADELPHIA PA
19142-1423
US

V. Phone/Fax

Practice location:
  • Phone: 215-726-0181
  • Fax: 215-726-5110
Mailing address:
  • Phone: 215-726-0181
  • Fax: 215-726-5110

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License NumberMD028686E
License Number StatePA
# 2
Primary TaxonomyY
Taxonomy Code208D00000X
TaxonomyGeneral Practice Physician
License NumberMD028686E
License Number StatePA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: