Healthcare Provider Details

I. General information

NPI: 1366024143
Provider Name (Legal Business Name): ROB TATUM
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 04/22/2021
Last Update Date: 04/28/2026
Certification Date: 04/28/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

111 COLCHESTER AVE
BURLINGTON VT
05401-1473
US

IV. Provider business mailing address

3401 N BROAD ST
PHILADELPHIA PA
19140-5189
US

V. Phone/Fax

Practice location:
  • Phone: 802-847-2345
  • Fax:
Mailing address:
  • Phone: 202-680-8859
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code2086S0129X
TaxonomyVascular Surgery Physician
License NumberMT232505
License Number StatePA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: