Provider Demographics
NPI:1871502260
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:770-812-9745
Mailing Address - Street 1:109 CEDAR ST STE C
Mailing Address - Street 2:
Mailing Address - City:CARROLLTON
Mailing Address - State:GA
Mailing Address - Zip Code:30117-2667
Mailing Address - Country:US
Mailing Address - Phone:770-812-5770
Mailing Address - Fax:770-836-9897
Practice Address - Street 1:101 DOCTORS DR
Practice Address - Street 2:
Practice Address - City:CARROLLTON
Practice Address - State:GA
Practice Address - Zip Code:30117-4486
Practice Address - Country:US
Practice Address - Phone:770-836-9697
Practice Address - Fax:770-836-9897
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:TANNER MEDICAL CENTER
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2006-08-05
Last Update Date:2024-10-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GANOT REQUIRED101Y00000X
GA022-426251S00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes251S00000XAgenciesCommunity/Behavioral Health
No101Y00000XBehavioral Health & Social Service ProvidersCounselorGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA300027104AOtherMEDICAID PAYEE IDENTIFICATION NUMBER
GA296667723AMedicaid