Provider Demographics
NPI:1396002515
Name:TANNER PRIMARY CARE OF WEDOWEE INC
Entity Type:Organization
Organization Name:TANNER PRIMARY CARE OF WEDOWEE INC
Other - Org Name:WEDOWEE RURAL HEALTH
Other - Org Type:Doing Business As
Authorized Official - Title/Position:SR VP
Authorized Official - Prefix:
Authorized Official - First Name:CLINT
Authorized Official - Middle Name:
Authorized Official - Last Name:HOFFMAN
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:770-812-8845
Mailing Address - Street 1:100 GREENWAY BLVD FL 2
Mailing Address - Street 2:
Mailing Address - City:CARROLLTON
Mailing Address - State:GA
Mailing Address - Zip Code:30117-4338
Mailing Address - Country:US
Mailing Address - Phone:770-838-8710
Mailing Address - Fax:770-812-5735
Practice Address - Street 1:1030 MAIN ST S
Practice Address - Street 2:
Practice Address - City:WEDOWEE
Practice Address - State:AL
Practice Address - Zip Code:36278-7440
Practice Address - Country:US
Practice Address - Phone:256-357-2188
Practice Address - Fax:256-357-2023
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2012-04-12
Last Update Date:2024-02-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes261QR1300XAmbulatory Health Care FacilitiesClinic/CenterRural Health
No207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
AL139022Medicaid
AL01-8904OtherRHC CERTIFICATION NUMBER
AL155218Medicaid
AL102G704647Medicare PIN