Provider Demographics
NPI:1487727186
Name:TANNENBAUM, RUSS (DC PA)
Entity type:Individual
Prefix:DR
First Name:RUSS
Middle Name:
Last Name:TANNENBAUM
Suffix:
Gender:M
Credentials:DC PA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5800 COLONIAL DRIVE
Mailing Address - Street 2:STE 305
Mailing Address - City:MARGATE
Mailing Address - State:FL
Mailing Address - Zip Code:33063
Mailing Address - Country:US
Mailing Address - Phone:954-979-2333
Mailing Address - Fax:954-968-8468
Practice Address - Street 1:5800 COLONIAL DRIVE
Practice Address - Street 2:STE 305
Practice Address - City:MARGATE
Practice Address - State:FL
Practice Address - Zip Code:33063
Practice Address - Country:US
Practice Address - Phone:954-587-4300
Practice Address - Fax:954-587-4018
Is Sole Proprietor?:Yes
Enumeration Date:2006-11-17
Last Update Date:2015-01-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLCH0004086111N00000X
FLCH4086111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes111N00000XChiropractic ProvidersChiropractor
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL380428300Medicaid
FL88856Medicare UPIN
FL380428300Medicaid