Basic Information
Provider Information | |||||||||
NPI: | 1033304381 | ||||||||
EntityType: | 1 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: |   | ||||||||
LastName: | TENNANT | ||||||||
FirstName: | JOSHUA | ||||||||
MiddleName: |   | ||||||||
NamePrefix: |   | ||||||||
NameSuffix: |   | ||||||||
Credential: | P.T. | ||||||||
OtherOrganizationName: |   | ||||||||
OtherOrganizationType: |   | ||||||||
OtherLastName: |   | ||||||||
OtherFirstName: |   | ||||||||
OtherMiddleName: |   | ||||||||
OtherNamePrefix: |   | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: |   | ||||||||
OtherLastNameType: |   | ||||||||
Mailing Information | |||||||||
Address1: | 7503 SURRATTS RD | ||||||||
Address2: |   | ||||||||
City: | CLINTON | ||||||||
State: | MD | ||||||||
PostalCode: | 207353358 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 3018707001 | ||||||||
FaxNumber: | 3018706697 | ||||||||
Practice Location | |||||||||
Address1: | 103 CENTENNIAL ST | ||||||||
Address2: | SUITE H | ||||||||
City: | LA PLATA | ||||||||
State: | MD | ||||||||
PostalCode: | 206465984 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 3019970172 | ||||||||
FaxNumber: | 3019970175 | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 09/10/2007 | ||||||||
LastUpdateDate: | 02/03/2012 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: | M | ||||||||
AuthorizedOfficialLastName: |   | ||||||||
AuthorizedOfficialFirstName: |   | ||||||||
AuthorizedOfficialMiddleName: |   | ||||||||
AuthorizedOfficialTitleorPosition: |   | ||||||||
AuthorizedOfficialTelephone: |   | ||||||||
IsSoleProprietor: | N | ||||||||
IsOrganizationSubpart: |   | ||||||||
ParentOrganizationLBN: |   | ||||||||
AuthorizedOfficialNamePrefix: |   | ||||||||
AuthorizedOfficialNameSuffix: |   | ||||||||
AuthorizedOfficialCredential: |   | ||||||||
NPICertificationDate: |   |
Taxonomy Information
Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 208100000X | T6108 | MD | N |   | Allopathic & Osteopathic Physicians | Physical Medicine & Rehabilitation |   | 225100000X | 11996 | OH | Y |   | Respiratory, Developmental, Rehabilitative and Restorative Service Providers | Physical Therapist |   |
No ID Information.