Individual
MATT TANNENBAUM
Active
Sole proprietor
No
Provider details
NPI number
Gender
Man
Credential
MD
Contact information
Practice address
3100 CHANNING WAY, IDAHO FALLS, ID 83404-7533
(208) 529-6050
(208) 529-7085
Mailing address
1820 E 17TH ST, STE 230, IDAHO FALLS, ID 83404-6521
(208) 529-9779
(208) 542-2756
Taxonomy
Speciality
Code
Description
License number
State
207ZP0102X
Anatomic Pathology & Clinical Pathology Physician
Primary
M7775
ID
Other
Other identifiers
Code
Description
Identifier
Issuer
State
01
—
000010005388
REGENCE BLUE SHIELD ID
ID
01
—
32946
BLUE CROSS OF ID
ID
05
—
805449000
—
ID
Enumeration date
03/10/2006
Last updated
12/27/2012
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