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Individual provider Active NPI

Matt Tannenbaum, MD

  • Anatomic Pathology & Clinical Pathology Physician
  • Idaho Falls, ID
National Provider Identifier
1093783375
Registry record updated Dec 27, 2012
On this page

Key facts

NPPES NPI Registry
Primary specialty
Anatomic Pathology & Clinical Pathology PhysicianTaxonomy code 207ZP0102X
License
M7775 Issued in ID
Practice address
3100 Channing Way
Idaho Falls, ID 83404-7533
Phone
(208) 529-6050
Fax
(208) 529-7085
NPI assigned
Mar 10, 2006
Sex
Male
Sole proprietor
No

NPPES NPI Registry

Updated by the provider on Dec 27, 2012

Registry information is reported by the provider to CMS and is not verified. About this source

Specialties & licenses 1

Specialty (taxonomy)CodeLicenseStatePrimary
Anatomic Pathology & Clinical Pathology Physician 207ZP0102X M7775 ID Primary

Addresses

Primary practice location

3100 Channing Way
Idaho Falls, ID 83404-7533

Mailing address

1820 E 17TH St
Ste 230
Idaho Falls, ID 83404-6521
Phone (208) 529-9779

Other identifiers 3

IdentifierTypeStateIssuer
000010005388OtherIDREGENCE BLUE SHIELD ID
805449000MedicaidID
32946OtherIDBLUE CROSS OF ID

Medicare participation

Medicare enrollment files
Medicare fee-for-service enrollment
Enrolled in ID
Eligible to order & refer
  • Part B services
  • Medical equipment
  • Home health
  • Power mobility devices
  • Hospice
Green means eligible to order or refer.

Enrollment records 1

Enrollment IDStateProvider typePAC IDDetails
I20100820000822 ID Practitioner - Pathology 0244329431 Reassigns benefits to 1 organization

Care Compare profile

Medicare Care Compare
Specialty
Pathology
Education
Albany Medical College of Union University, 1993
Medicare assignment
Accepts the Medicare-approved amount as payment in full
Group practices
Mountain View Hospital LLCGroup PAC ID 4486562774, 272 clinicians

Practice addresses (Care Compare)

2325 Coronado St
Idaho Falls, ID 83404-7407
Phone (208) 557-2700

Hospital & facility affiliations

  • Mountain View Hospital Hospital, Idaho Falls, ID, CCN 130065
  • Eastern Idaho Regional Medical Center Hospital, Idaho Falls, ID, CCN 130018
  • Idaho Falls Community Hospital, LLC Hospital, Idaho Falls, ID, CCN 130074
  • Steele Memorial Medical Center Hospital, Salmon, ID, CCN 131305
  • Star Valley Medical Center Hospital, Afton, WY, CCN 531313

National Provider Directory

National Provider Directory
Medicare enrollment (NPD)
Enrolled
Credentials
Doctor of Medicine

State licenses

LicenseStateTypeSpecialty
M7775IDMDAnatomic Pathology & Clinical Pathology Physician

Practice roles

OrganizationSpecialtyStatusNew patients
Mountain View Hospital LLC CurrentSince Apr 1, 2024 Accepting new patients
Obstetrics and Gynecology Associates of Idaho Falls Current Accepting new patients
Pathology Associates of Idaho Falls P a Anatomic Pathology & Clinical Pathology CurrentSince Jun 28, 1999 Accepting new patients

Locations

3100 Channing Way
Idaho Falls, ID 83404
Phone (208) 227-2100

2325 Coronado St
Idaho Falls, ID 83404
Phone (208) 528-7686

1820 E 17th St
Ste 230
Idaho Falls, ID 83404
Phone (208) 201-0408

5700 Southwyck Blvd
Toledo, OH 43614

Organizations & group practices 3

Organizations this provider is connected to: Medicare benefit reassignments (the organization bills Medicare for this provider’s services), Care Compare group memberships and National Provider Directory roles.

Hospital & facility affiliations 5

Hospitals and other facilities this clinician is affiliated with according to Medicare Care Compare.

NPI Registry JSON

The complete NPPES record for this NPI in the NPI Registry API format.

{
    "created_epoch": "1141948800000",
    "enumeration_type": "NPI-1",
    "last_updated_epoch": "1356566400000",
    "number": "1093783375",
    "addresses": [
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "MAILING",
            "address_type": "DOM",
            "address_1": "1820 E 17TH ST",
            "address_2": "STE 230",
            "city": "IDAHO FALLS",
            "state": "ID",
            "postal_code": "834046521",
            "telephone_number": "208-529-9779",
            "fax_number": "208-542-2756"
        },
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "LOCATION",
            "address_type": "DOM",
            "address_1": "3100 CHANNING WAY",
            "city": "IDAHO FALLS",
            "state": "ID",
            "postal_code": "834047533",
            "telephone_number": "208-529-6050",
            "fax_number": "208-529-7085"
        }
    ],
    "practiceLocations": [],
    "basic": {
        "last_name": "TANNENBAUM",
        "first_name": "MATT",
        "credential": "MD",
        "sole_proprietor": "NO",
        "sex": "M",
        "enumeration_date": "2006-03-10",
        "last_updated": "2012-12-27",
        "status": "A"
    },
    "taxonomies": [
        {
            "code": "207ZP0102X",
            "taxonomy_group": "",
            "desc": "Pathology, Anatomic Pathology & Clinical Pathology",
            "state": "ID",
            "license": "M7775",
            "primary": true
        }
    ],
    "identifiers": [
        {
            "code": "01",
            "desc": "Other (non-Medicare)",
            "issuer": "REGENCE BLUE SHIELD ID",
            "identifier": "000010005388",
            "state": "ID"
        },
        {
            "code": "05",
            "desc": "MEDICAID",
            "issuer": null,
            "identifier": "805449000",
            "state": "ID"
        },
        {
            "code": "01",
            "desc": "Other (non-Medicare)",
            "issuer": "BLUE CROSS OF ID",
            "identifier": "32946",
            "state": "ID"
        }
    ],
    "endpoints": [],
    "other_names": []
}

Other providers in Idaho Falls, ID

Sources for this page

Verify at the official NPI Registry.