Provider Demographics
NPI:1326031865
Name:TANNER, MARSHALL GLYNN (MD)
Entity Type:Individual
Prefix:DR
First Name:MARSHALL
Middle Name:GLYNN
Last Name:TANNER
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:710 N IRWIN AVE
Mailing Address - Street 2:SUITE 106
Mailing Address - City:OCILLA
Mailing Address - State:GA
Mailing Address - Zip Code:31774-5011
Mailing Address - Country:US
Mailing Address - Phone:229-468-3800
Mailing Address - Fax:229-468-9991
Practice Address - Street 1:2016 OCILLA RD
Practice Address - Street 2:
Practice Address - City:DOUGLAS
Practice Address - State:GA
Practice Address - Zip Code:31533-2230
Practice Address - Country:US
Practice Address - Phone:912-384-4010
Practice Address - Fax:912-384-4018
Is Sole Proprietor?:No
Enumeration Date:2005-08-30
Last Update Date:2016-04-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA056658207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA00567102TMedicaid
GA202I117502Medicare PIN
GA000567102CMedicaid
GAGRP7301Medicare PIN
GA000567102EOtherMEDICAID-WILLACOOCHEE
GA000567102GOtherMEDICAID - NICHOLLS
GA056658OtherSTATE LICENSE