Provider Demographics
NPI:1528085412
Name:TALLENT, PHILLIP G (MD)
Entity type:Individual
Prefix:
First Name:PHILLIP
Middle Name:G
Last Name:TALLENT
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
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Mailing Address - Street 1:721 GLENWOOD DRIVE
Mailing Address - Street 2:SUITE 467
Mailing Address - City:CHATTANOOGA
Mailing Address - State:TN
Mailing Address - Zip Code:37404
Mailing Address - Country:US
Mailing Address - Phone:423-698-3423
Mailing Address - Fax:423-698-1380
Practice Address - Street 1:721 GLENWOOD DRIVE
Practice Address - Street 2:SUITE 467
Practice Address - City:CHATTANOOGA
Practice Address - State:TN
Practice Address - Zip Code:37404
Practice Address - Country:US
Practice Address - Phone:423-698-3423
Practice Address - Fax:423-698-1380
Is Sole Proprietor?:Yes
Enumeration Date:2006-07-16
Last Update Date:2019-03-15
Deactivation Date:
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Provider Licenses
StateLicense IDTaxonomies
MN1024922084N0400X
MN490632084N0400X
TN423092084S0012X, 2084N0400X
GA0572552084S0012X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2084N0400XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyNeurology
No2084S0012XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologySleep Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
TN3000643Medicaid
MN036992000Medicaid
TN3000643Medicaid
MN036992000Medicaid
MN036992000Medicaid