MEDICARE: MS. MARY R. TANNEY CRNP

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	363L00000X	Nurse Practitioner	TP001695D	PA

General Provider Information

NPI Number	:	1740263904
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MS. MARY R. TANNEY CRNP

Provider Business Mailing Address
First Line	:	3550 MARKET ST
Second Line	:	ADOLESCENT CARE CENTER - 4TH FLOOR
City	:	PHILADELPHIA
State	:	PA
Zip	:	19104-3329
Country	:	US
Telephone Number	:	215-590-1000
Fax Number	:	215-590-0426

Provider Business Practice Location Address
First Line	:	3550 MARKET ST
Second Line	:	ADOLESCENT CARE CENTER - 4TH FLOOR
City	:	PHILADELPHIA
State	:	PA
Zip	:	19104-3329
Country	:	US
Telephone Number	:	215-590-1000
Fax Number	:	215-590-0426

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

Provider Enumeration Date	:	11/22/2005
Last Update Date	:	07/08/2007

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