MEDICARE: DR. JORDAN M 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	208000000X	Pediatrics Physician	149788	NY

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
2	002892901	OTHER	NY	BLUE CROSS BLUE SHIELD

General Provider Information

NPI Number	:	1922000116
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	DR. JORDAN M TANNENBAUM M.D.

Provider Business Mailing Address
First Line	:	1 FOX CARE DR
Second Line	:	STE 213
City	:	ONEONTA
State	:	NY
Zip	:	13820-2086
Country	:	US
Telephone Number	:	607-432-5600
Fax Number	:	607-431-5275

Provider Business Practice Location Address
First Line	:	1 FOX CARE DR
Second Line	:	STE 213
City	:	ONEONTA
State	:	NY
Zip	:	13820-2086
Country	:	US
Telephone Number	:	607-432-5600
Fax Number	:	607-431-5275

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

Provider Enumeration Date	:	06/01/2005
Last Update Date	:	06/29/2010

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