Provider Demographics
NPI:1467737759
Name:TANNER, GREGORY W (MD)
Entity Type:Individual
Prefix:
First Name:GREGORY
Middle Name:W
Last Name:TANNER
Suffix:
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 1:501 PARK HILL DR
Mailing Address - Street 2:
Mailing Address - City:FREDERICKSBURG
Mailing Address - State:VA
Mailing Address - Zip Code:22401-3377
Mailing Address - Country:US
Mailing Address - Phone:540-372-6737
Mailing Address - Fax:540-372-3510
Practice Address - Street 1:5899 BREMO RD STE 100
Practice Address - Street 2:
Practice Address - City:RICHMOND
Practice Address - State:VA
Practice Address - Zip Code:23226-1935
Practice Address - Country:US
Practice Address - Phone:804-288-8512
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2011-10-18
Last Update Date:2022-05-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA0101264607207X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207X00000XAllopathic & Osteopathic PhysiciansOrthopaedic Surgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL018369300Medicaid
FLB6960OtherBCBS
FLIT387ZMedicare PIN