MEDICARE: LUCILE BORDEN TENNANT 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	207ZP0102X	Anatomic Pathology & Clinical Pathology Physician	J2370	TX
2	207ZP0102X	Anatomic Pathology & Clinical Pathology Physician	46948	WI
3	207ZP0102X	Anatomic Pathology & Clinical Pathology Physician	202858	NY
4	207ZP0102X	Anatomic Pathology & Clinical Pathology Physician	209822	MA

General Provider Information

NPI Number	:	1831170992
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	LUCILE BORDEN TENNANT MD

Provider Business Mailing Address
First Line	:	PO BOX 164106
Second Line	:
City	:	AUSTIN
State	:	TX
Zip	:	78716-4106
Country	:	US
Telephone Number	:	512-324-7516
Fax Number	:	512-324-7536

Provider Business Practice Location Address
First Line	:	601 E 15TH ST
Second Line	:	PATHOLOGY DEPARTMENT
City	:	AUSTIN
State	:	TX
Zip	:	78701-1930
Country	:	US
Telephone Number	:	812-324-7516
Fax Number	:	512-324-7536

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

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

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