Provider Demographics
NPI:1104850965
Name:TANNER MEDICAL CENTER, INC.
Entity Type:Organization
Organization Name:TANNER MEDICAL CENTER, INC.
Other - Org Name:TANNER BOUTIQUE
Other - Org Type:Doing Business As
Authorized Official - Title/Position:CFO
Authorized Official - Prefix:MR
Authorized Official - First Name:LEE
Authorized Official - Middle Name:C
Authorized Official - Last Name:SHERSETH
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:770-836-9697
Mailing Address - Street 1:705 DIXIE ST
Mailing Address - Street 2:
Mailing Address - City:CARROLLTON
Mailing Address - State:GA
Mailing Address - Zip Code:30117-3818
Mailing Address - Country:US
Mailing Address - Phone:770-836-9697
Mailing Address - Fax:770-836-9897
Practice Address - Street 1:157 CLINIC AVE
Practice Address - Street 2:SUITE 202
Practice Address - City:CARROLLTON
Practice Address - State:GA
Practice Address - Zip Code:30117-4454
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, INC.
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2006-07-10
Last Update Date:2009-03-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA004396332B00000X, 335E00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes332B00000XSuppliersDurable Medical Equipment & Medical Supplies
No335E00000XSuppliersProsthetic/Orthotic Supplier
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA000001867BMedicaid
GA000001867CMedicaid
110011Medicare Oscar/Certification
GA5732190001Medicare NSC