Provider Demographics
NPI:1053349928
Name:TANNENBAUM, DARRYL A (MD)
Entity type:Individual
Prefix:
First Name:DARRYL
Middle Name:A
Last Name:TANNENBAUM
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 1:940 N MARR RD
Mailing Address - Street 2:SUITE C
Mailing Address - City:COLUMBUS
Mailing Address - State:IN
Mailing Address - Zip Code:47201-2610
Mailing Address - Country:US
Mailing Address - Phone:812-376-9353
Mailing Address - Fax:812-376-3757
Practice Address - Street 1:940 N MARR RD
Practice Address - Street 2:SUITE C
Practice Address - City:COLUMBUS
Practice Address - State:IN
Practice Address - Zip Code:47201-2610
Practice Address - Country:US
Practice Address - Phone:812-376-9353
Practice Address - Fax:812-376-3757
Is Sole Proprietor?:No
Enumeration Date:2006-06-29
Last Update Date:2010-01-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN1046006207X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207X00000XAllopathic & Osteopathic PhysiciansOrthopaedic Surgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
IN003842OtherSIHO
IN200040850OtherRAILROAD MEDICARE
IN000000195467OtherANTHEM
IN200127230Medicaid
IN000000195467OtherANTHEM
IN200127230Medicaid
IN4207900005Medicare NSC