Provider Demographics
NPI:1417072596
Name:EISENBERG, TARA RAQUEL (MD)
Entity type:Individual
Prefix:
First Name:TARA
Middle Name:RAQUEL
Last Name:EISENBERG
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:TARA
Other - Middle Name:RAQUEL
Other - Last Name:HERZBERG
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:MD
Mailing Address - Street 1:111 S 11TH ST
Mailing Address - Street 2:SUITE 3390
Mailing Address - City:PHILADELPHIA
Mailing Address - State:PA
Mailing Address - Zip Code:19107-4824
Mailing Address - Country:US
Mailing Address - Phone:215-955-6226
Mailing Address - Fax:215-923-1562
Practice Address - Street 1:111 S 11TH ST
Practice Address - Street 2:SUITE 3390
Practice Address - City:PHILADELPHIA
Practice Address - State:PA
Practice Address - Zip Code:19107-4824
Practice Address - Country:US
Practice Address - Phone:215-955-6226
Practice Address - Fax:215-923-1562
Is Sole Proprietor?:No
Enumeration Date:2007-03-20
Last Update Date:2010-06-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PAMD4372942085R0202X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2085R0202XAllopathic & Osteopathic PhysiciansRadiologyDiagnostic Radiology
Provider Identifiers
StateIdentifier IDID TypeIssuer
NC145XUOtherBCBSNC
PA102337804Medicaid
NC5907571Medicaid
PA102337804Medicaid
NC2069081AMedicare PIN