Provider Demographics
NPI:1184646309
Name:TANNER, ALICE (MD)
Entity Type:Individual
Prefix:DR
First Name:ALICE
Middle Name:
Last Name:TANNER
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
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Other - Last Name:
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Other - Credentials:
Mailing Address - Street 1:1404 CRAIN HWY S
Mailing Address - Street 2:SUITE 109
Mailing Address - City:GLEN BURNIE
Mailing Address - State:MD
Mailing Address - Zip Code:21061-4085
Mailing Address - Country:US
Mailing Address - Phone:410-768-2231
Mailing Address - Fax:410-760-4522
Practice Address - Street 1:1404 CRAIN HWY S
Practice Address - Street 2:SUITE 109
Practice Address - City:GLEN BURNIE
Practice Address - State:MD
Practice Address - Zip Code:21061-4085
Practice Address - Country:US
Practice Address - Phone:410-768-2231
Practice Address - Fax:410-760-4522
Is Sole Proprietor?:Yes
Enumeration Date:2006-07-24
Last Update Date:2015-11-18
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
MDD0032734208000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208000000XAllopathic & Osteopathic PhysiciansPediatrics
Provider Identifiers
StateIdentifier IDID TypeIssuer
MD407731800Medicaid
MD354440-01OtherBLUE CROSS &BLUE SHIELD
MD407731800Medicaid