MEDICARE: JUDITH ANN TANENBAUM PAC

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	363A00000X	Physician Assistant	MA002088L	PA

General Provider Information

NPI Number	:	1184601627
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	JUDITH ANN TANENBAUM PAC

Provider Business Mailing Address
First Line	:	623 UNRUH AVE
Second Line	:	2ND FL
City	:	PHILA
State	:	PA
Zip	:	19111
Country	:	US
Telephone Number	:	215-214-1094
Fax Number	:	215-214-1098

Provider Business Practice Location Address
First Line	:	2100 W GIRARD AVE
Second Line	:
City	:	PHILA
State	:	PA
Zip	:	19130
Country	:	US
Telephone Number	:	215-214-1094
Fax Number	:	215-214-1098

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

Provider Enumeration Date	:	12/27/2005
Last Update Date	:	07/08/2007

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