Provider Demographics
NPI:1417174269
Name:TANNER, SUSAN L (MD)
Entity Type:Individual
Prefix:DR
First Name:SUSAN
Middle Name:L
Last Name:TANNER
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
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Other - Credentials:
Mailing Address - Street 1:3200 DOWNWOOD CIR NW
Mailing Address - Street 2:SUITE 520
Mailing Address - City:ATLANTA
Mailing Address - State:GA
Mailing Address - Zip Code:30327-1610
Mailing Address - Country:US
Mailing Address - Phone:404-845-7484
Mailing Address - Fax:404-549-3005
Practice Address - Street 1:3200 DOWNWOOD CIR NW
Practice Address - Street 2:SUITE 520
Practice Address - City:ATLANTA
Practice Address - State:GA
Practice Address - Zip Code:30327-1610
Practice Address - Country:US
Practice Address - Phone:404-845-7484
Practice Address - Fax:404-549-3005
Is Sole Proprietor?:Yes
Enumeration Date:2007-04-20
Last Update Date:2011-02-10
Deactivation Date:
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Provider Licenses
StateLicense IDTaxonomies
GA25488207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA582645783OtherFEDERAL TAX ID