Basic Information
| Provider Information | |||||||||
| NPI: | 1285922724 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | TANNEBAUM | ||||||||
| FirstName: | JONATHAN | ||||||||
| MiddleName: | ETHAN | ||||||||
| NamePrefix: | DR. | ||||||||
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| Credential: | MD | ||||||||
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| Mailing Information | |||||||||
| Address1: | 908 NIAGARA FALLS BLVD STE 208 | ||||||||
| Address2: | |||||||||
| City: | NORTH TONAWANDA | ||||||||
| State: | NY | ||||||||
| PostalCode: | 141202019 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7166923302 | ||||||||
| FaxNumber: | 7166924342 | ||||||||
| Practice Location | |||||||||
| Address1: | 251 N 4TH ST | ||||||||
| Address2: | |||||||||
| City: | OAKLAND | ||||||||
| State: | MD | ||||||||
| PostalCode: | 215501375 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3015334000 | ||||||||
| FaxNumber: | 3018958751 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 07/19/2011 | ||||||||
| LastUpdateDate: | 08/16/2021 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 08/16/2021 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 208600000X | 275818 | NY | Y | Allopathic & Osteopathic Physicians | Surgery |
ID Information
| ID | Type | State | Issuer | Description | 1H0698 | 01 | MD | MEDICAR PTAN | OTHER | 996022880 | 05 | MD | MEDICAID |