Provider Demographics
NPI:1083096366
Name:TANNER, ELIZABETH PARK (MD)
Entity Type:Individual
Prefix:
First Name:ELIZABETH
Middle Name:PARK
Last Name:TANNER
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 640
Mailing Address - Street 2:
Mailing Address - City:HOLLYWOOD
Mailing Address - State:MD
Mailing Address - Zip Code:20636-0640
Mailing Address - Country:US
Mailing Address - Phone:301-373-7900
Mailing Address - Fax:301-373-6900
Practice Address - Street 1:950 E SWAN CREEK RD
Practice Address - Street 2:
Practice Address - City:FORT WASHINGTON
Practice Address - State:MD
Practice Address - Zip Code:20744-5250
Practice Address - Country:US
Practice Address - Phone:301-373-7900
Practice Address - Fax:301-373-6900
Is Sole Proprietor?:No
Enumeration Date:2015-06-23
Last Update Date:2021-12-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
RILP03517207R00000X
MDD91656207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine