Provider Demographics
NPI:1447348131
Name:TANNER, BRADLEY (MD)
Entity type:Individual
Prefix:
First Name:BRADLEY
Middle Name:
Last Name:TANNER
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:TODD
Other - Middle Name:BRADLEY
Other - Last Name:TANNER
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:MD
Mailing Address - Street 1:101 MARKET ST STE A
Mailing Address - Street 2:
Mailing Address - City:CHAPEL HILL
Mailing Address - State:NC
Mailing Address - Zip Code:27516-4070
Mailing Address - Country:US
Mailing Address - Phone:919-579-7047
Mailing Address - Fax:919-843-5515
Practice Address - Street 1:101 MANNING DR
Practice Address - Street 2:
Practice Address - City:CHAPEL HILL
Practice Address - State:NC
Practice Address - Zip Code:27599-0001
Practice Address - Country:US
Practice Address - Phone:919-966-8596
Practice Address - Fax:919-843-5515
Is Sole Proprietor?:No
Enumeration Date:2006-10-10
Last Update Date:2021-09-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC0098-010802084P0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2084P0800XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyPsychiatry
Provider Identifiers
StateIdentifier IDID TypeIssuer
NC891240VMedicaid
NC2279846Medicare ID - Type Unspecified
NC891240VMedicaid