MEDICARE: DR. LEE ERIC TANNENBAUM M.D.

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	207QA0401X	Addiction Medicine (Family Medicine) Physician	D39763	MD
2	207QA0505X	Adult Medicine Physician	D39763	MD

General Provider Information

NPI Number	:	1528030004
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	DR. LEE ERIC TANNENBAUM M.D.

Provider Business Mailing Address
First Line	:	2012 S TOLLGATE RD
Second Line	:	STE 106
City	:	BEL AIR
State	:	MD
Zip	:	21015-5900
Country	:	US
Telephone Number	:	410-569-9429
Fax Number	:	410-569-9423

Provider Business Practice Location Address
First Line	:	2012 S TOLLGATE RD
Second Line	:	STE 106
City	:	BEL AIR
State	:	MD
Zip	:	21015-5900
Country	:	US
Telephone Number	:	410-569-9429
Fax Number	:	410-569-9423

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

Provider Enumeration Date	:	02/07/2006
Last Update Date	:	05/22/2008

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