Provider Demographics
NPI:1083639306
Name:TANNER, REBEKAH ELLEN (MD)
Entity Type:Individual
Prefix:
First Name:REBEKAH
Middle Name:ELLEN
Last Name:TANNER
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:REBEKAH
Other - Middle Name:ELLEN
Other - Last Name:ANSTADT
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:
Mailing Address - Street 1:7 DOCK HILL RD
Mailing Address - Street 2:
Mailing Address - City:MIDDLEBURG
Mailing Address - State:PA
Mailing Address - Zip Code:17842-8910
Mailing Address - Country:US
Mailing Address - Phone:570-837-2123
Mailing Address - Fax:570-837-2185
Practice Address - Street 1:137 FOREST HILL RD
Practice Address - Street 2:
Practice Address - City:MIFFLINBURG
Practice Address - State:PA
Practice Address - Zip Code:17844-7066
Practice Address - Country:US
Practice Address - Phone:570-966-1004
Practice Address - Fax:570-966-3736
Is Sole Proprietor?:Yes
Enumeration Date:2006-07-13
Last Update Date:2015-12-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PAMD429690207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
PA1017024590002Medicaid
PA186790F6KMedicare PIN
PA7861817OtherAETNA
PAI62156OtherHEALTHAMERICA
PA002812OtherFIRST PRIORITY HEALTH
PA1877123OtherHIGHMARK BLUE SHIELD
PA186790Medicare PIN
PA820601OtherFIRST PRIORITY HEALTH
I62156Medicare UPIN