Provider Demographics
NPI:1366529083
Name:TAVOULARIS, MARJORIE OSTERWISE (MD)
Entity type:Individual
Prefix:
First Name:MARJORIE
Middle Name:OSTERWISE
Last Name:TAVOULARIS
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1340 W PITTSBURGH ST
Mailing Address - Street 2:
Mailing Address - City:SCOTTDALE
Mailing Address - State:PA
Mailing Address - Zip Code:15683-2600
Mailing Address - Country:US
Mailing Address - Phone:724-220-2422
Mailing Address - Fax:
Practice Address - Street 1:1340 W PITTSBURGH ST
Practice Address - Street 2:
Practice Address - City:SCOTTDALE
Practice Address - State:PA
Practice Address - Zip Code:15683-2600
Practice Address - Country:US
Practice Address - Phone:724-771-2736
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2006-11-01
Last Update Date:2012-06-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAG0565652084P0800X
PAMD009524E2084P0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2084P0800XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyPsychiatry