Provider Demographics
NPI:1386797017
Name:EDWARD C TANNER MD PC
Entity type:Organization
Organization Name:EDWARD C TANNER MD PC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:EDWARD
Authorized Official - Middle Name:C
Authorized Official - Last Name:TANNER
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:585-266-2583
Mailing Address - Street 1:1445 PORTLAND AVE
Mailing Address - Street 2:
Mailing Address - City:ROCHESTER
Mailing Address - State:NY
Mailing Address - Zip Code:14621
Mailing Address - Country:US
Mailing Address - Phone:585-266-2583
Mailing Address - Fax:585-266-5363
Practice Address - Street 1:1445 PORTLAND AVE
Practice Address - Street 2:
Practice Address - City:ROCHESTER
Practice Address - State:NY
Practice Address - Zip Code:14621
Practice Address - Country:US
Practice Address - Phone:585-266-2583
Practice Address - Fax:585-266-5363
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-01-18
Last Update Date:2008-01-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY14075 1207X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207X00000XAllopathic & Osteopathic PhysiciansOrthopaedic SurgeryGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
102336CUOtherPREFERRED CARE
NY00593559Medicaid
NY00593559Medicaid
NYAA0400Medicare PIN