MEDICARE: JEFFREY P TANNENBAUM MD

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	207Q00000X	Family Medicine Physician	77474	MA

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program

General Provider Information

NPI Number	:	1699761155
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	JEFFREY P TANNENBAUM MD

Provider Business Mailing Address
First Line	:	680 CENTRE ST
Second Line	:
City	:	BROCKTON
State	:	MA
Zip	:	02302-3308
Country	:	US
Telephone Number	:	508-941-7000
Fax Number	:

Provider Business Practice Location Address
First Line	:	430 LIBERTY ST
Second Line	:	SUITE 7
City	:	HANSON
State	:	MA
Zip	:	02341-1113
Country	:	US
Telephone Number	:	781-293-3838
Fax Number	:	781-293-3639

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

Provider Enumeration Date	:	09/21/2005
Last Update Date	:	09/18/2018

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