Provider Demographics
NPI:1306356035
Name:TANNER MEDICAL CENTER, INC
Entity type:Organization
Organization Name:TANNER MEDICAL CENTER, INC
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:CFO
Authorized Official - Prefix:
Authorized Official - First Name:CAROL
Authorized Official - Middle Name:S
Authorized Official - Last Name:CREWS
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:770-812-9580
Mailing Address - Street 1:100 PROFESSIONAL PL STE 305
Mailing Address - Street 2:
Mailing Address - City:CARROLLTON
Mailing Address - State:GA
Mailing Address - Zip Code:30117-3872
Mailing Address - Country:US
Mailing Address - Phone:770-812-8614
Mailing Address - Fax:
Practice Address - Street 1:100 PROFESSIONAL PL STE 307
Practice Address - Street 2:
Practice Address - City:CARROLLTON
Practice Address - State:GA
Practice Address - Zip Code:30117-3872
Practice Address - Country:US
Practice Address - Phone:770-812-9146
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:TANNER MEDICAL CENTER, INC.
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2017-10-09
Last Update Date:2017-10-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QS1200XAmbulatory Health Care FacilitiesClinic/CenterSleep Disorder Diagnostic
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA1867CMedicaid