Provider Demographics
NPI:1114911294
Name:TANNER, WILLIAM GORDON JR (MD)
Entity Type:Individual
Prefix:DR
First Name:WILLIAM
Middle Name:GORDON
Last Name:TANNER
Suffix:JR
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:721 WELLNESS WAY
Mailing Address - Street 2:STE 100
Mailing Address - City:LAWRENCEVILLE
Mailing Address - State:GA
Mailing Address - Zip Code:30046-3304
Mailing Address - Country:US
Mailing Address - Phone:770-995-7989
Mailing Address - Fax:770-339-8646
Practice Address - Street 1:721 WELLNESS WAY
Practice Address - Street 2:STE 100
Practice Address - City:LAWRENCEVILLE
Practice Address - State:GA
Practice Address - Zip Code:30046-3304
Practice Address - Country:US
Practice Address - Phone:770-995-7989
Practice Address - Fax:770-339-8646
Is Sole Proprietor?:No
Enumeration Date:2005-09-06
Last Update Date:2012-09-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA046817207RG0100X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RG0100XAllopathic & Osteopathic PhysiciansInternal MedicineGastroenterology
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA52237427OtherBLUE CROSS BLUE SHIELD
GA582061514007OtherPRUDENTIAL
GA8485OtherONE HEALTH
GA00828396BMedicaid
GA7231009OtherMANAGE CARE
GA100014260OtherRAIL ROAD MEDICARE
GA29-00016OtherUNITED HEALTH CARE
GA8485OtherPROMINA
GA695067Medicare UPIN
GA8485OtherONE HEALTH