Provider Demographics
NPI:1528030004
Name:TANNENBAUM, LEE ERIC (MD)
Entity type:Individual
Prefix:DR
First Name:LEE
Middle Name:ERIC
Last Name:TANNENBAUM
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Credentials:
Mailing Address - Street 1:2012 S TOLLGATE RD
Mailing Address - Street 2:STE 106
Mailing Address - City:BEL AIR
Mailing Address - State:MD
Mailing Address - Zip Code:21015-5900
Mailing Address - Country:US
Mailing Address - Phone:410-569-9429
Mailing Address - Fax:410-569-9423
Practice Address - Street 1:2012 S TOLLGATE RD
Practice Address - Street 2:STE 106
Practice Address - City:BEL AIR
Practice Address - State:MD
Practice Address - Zip Code:21015-5900
Practice Address - Country:US
Practice Address - Phone:410-569-9429
Practice Address - Fax:410-569-9423
Is Sole Proprietor?:No
Enumeration Date:2006-02-07
Last Update Date:2008-05-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MDD39763207QA0401X, 207QA0505X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207QA0401XAllopathic & Osteopathic PhysiciansFamily MedicineAddiction Medicine
No207QA0505XAllopathic & Osteopathic PhysiciansFamily MedicineAdult Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
MDF00184Medicare UPIN
MD927AMedicare ID - Type UnspecifiedMEDICARE