Provider Demographics
NPI:1508180712
Name:TANYA R. SELLERS-HANNIBAL, DPM, PC
Entity Type:Organization
Organization Name:TANYA R. SELLERS-HANNIBAL, DPM, PC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:TANYA
Authorized Official - Middle Name:R
Authorized Official - Last Name:SELLERS-HANNIBAL
Authorized Official - Suffix:
Authorized Official - Credentials:DPM
Authorized Official - Phone:410-581-8331
Mailing Address - Street 1:10085 RED RUN BLVD
Mailing Address - Street 2:SUITE 305
Mailing Address - City:OWINGS MILLS
Mailing Address - State:MD
Mailing Address - Zip Code:21117-4836
Mailing Address - Country:US
Mailing Address - Phone:410-581-8331
Mailing Address - Fax:410-581-8332
Practice Address - Street 1:10085 RED RUN BLVD
Practice Address - Street 2:SUITE 305
Practice Address - City:OWINGS MILLS
Practice Address - State:MD
Practice Address - Zip Code:21117-4836
Practice Address - Country:US
Practice Address - Phone:410-581-8331
Practice Address - Fax:410-581-8332
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2010-03-16
Last Update Date:2010-03-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MD01173213E00000X, 213ES0131X
DCPO543213E00000X, 213ES0131X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes213ES0131XPodiatric Medicine & Surgery Service ProvidersPodiatristFoot SurgeryGroup - Single Specialty
No213E00000XPodiatric Medicine & Surgery Service ProvidersPodiatristGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
MD119128400Medicaid
MDU47525Medicare UPIN
MD119128400Medicaid