Provider Demographics
NPI:1215981600
Name:TANNER, PHILIP EDWIN (MD)
Entity type:Individual
Prefix:
First Name:PHILIP
Middle Name:EDWIN
Last Name:TANNER
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 1:1500 W 22ND ST
Mailing Address - Street 2:SUITE 101
Mailing Address - City:SIOUX FALLS
Mailing Address - State:SD
Mailing Address - Zip Code:57105-7702
Mailing Address - Country:US
Mailing Address - Phone:605-328-8500
Mailing Address - Fax:605-328-8501
Practice Address - Street 1:1500 W 22ND ST
Practice Address - Street 2:SUITE 101
Practice Address - City:SIOUX FALLS
Practice Address - State:SD
Practice Address - Zip Code:57105-7702
Practice Address - Country:US
Practice Address - Phone:605-328-8500
Practice Address - Fax:605-328-8501
Is Sole Proprietor?:No
Enumeration Date:2006-05-20
Last Update Date:2008-05-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SD5757207R00000X, 207RG0100X
MN43803207R00000X, 207RG0100X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RG0100XAllopathic & Osteopathic PhysiciansInternal MedicineGastroenterology
No207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
SDS100761Medicare PIN
F47430Medicare UPIN
SDP00307989Medicare PIN