Provider Demographics
NPI:1013184159
Name:ALICE TANNER M.D.,PC
Entity Type:Organization
Organization Name:ALICE TANNER M.D.,PC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PEDIATRICIAN/PRACTICE OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:ALICE
Authorized Official - Middle Name:PATRICIA
Authorized Official - Last Name:TANNER
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:410-768-2231
Mailing Address - Street 1:1406 CRAIN HWY S
Mailing Address - Street 2:SUITE 104
Mailing Address - City:GLEN BURNIE
Mailing Address - State:MD
Mailing Address - Zip Code:21061-4058
Mailing Address - Country:US
Mailing Address - Phone:410-768-2231
Mailing Address - Fax:410-760-4522
Practice Address - Street 1:1406 CRAIN HWY S
Practice Address - Street 2:SUITE 104
Practice Address - City:GLEN BURNIE
Practice Address - State:MD
Practice Address - Zip Code:21061-4058
Practice Address - Country:US
Practice Address - Phone:410-768-2231
Practice Address - Fax:410-760-4522
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-05-08
Last Update Date:2008-05-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes2080A0000XAllopathic & Osteopathic PhysiciansPediatricsAdolescent MedicineGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
MD215896500Medicaid