Provider Demographics
NPI:1831195619
Name:TISNOWER, HERBERT (MD)
Entity type:Individual
Prefix:DR
First Name:HERBERT
Middle Name:
Last Name:TISNOWER
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1837 S 65TH ST
Mailing Address - Street 2:
Mailing Address - City:PHILADELPHIA
Mailing Address - State:PA
Mailing Address - Zip Code:19142-1423
Mailing Address - Country:US
Mailing Address - Phone:215-726-0181
Mailing Address - Fax:215-726-5110
Practice Address - Street 1:1837 S 65TH ST
Practice Address - Street 2:
Practice Address - City:PHILADELPHIA
Practice Address - State:PA
Practice Address - Zip Code:19142-1423
Practice Address - Country:US
Practice Address - Phone:215-726-0181
Practice Address - Fax:215-726-5110
Is Sole Proprietor?:Yes
Enumeration Date:2005-06-25
Last Update Date:2022-09-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PAMD028686E207Q00000X, 208D00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208D00000XAllopathic & Osteopathic PhysiciansGeneral Practice
No207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
PA0009887700002Medicaid
PA0035661000OtherPERSONAL CHOICE PPO OF PENNSYLVANIA (INDEPENDENT BLC)
PA0035661000OtherIBC PERSONAL CHOICE
PA232626909OtherTRICARE PALMETTO (REGIONS 1-6)
PA232626909OtherTRICARE FOR LIFE
PA080019943OtherRAILROAD MEDICARE
PA0035661001OtherPENNSYLVANIA KEYSTONE HEALTH PLAN EAST
PA1831195619OtherKEYSTONE FIRST
PA232626909OtherTRICARE FOR LIFE