Provider Demographics
NPI:1508185190
Name:TANNER MEDICAL ENTERPRISES, INC
Entity Type:Organization
Organization Name:TANNER MEDICAL ENTERPRISES, INC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:ADMINISTRATOR/OWNER
Authorized Official - Prefix:
Authorized Official - First Name:MILLICENT
Authorized Official - Middle Name:H
Authorized Official - Last Name:TANNER
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:904-241-2653
Mailing Address - Street 1:PO BOX 51595
Mailing Address - Street 2:
Mailing Address - City:JACKSONVILLE BEACH
Mailing Address - State:FL
Mailing Address - Zip Code:32240-1595
Mailing Address - Country:US
Mailing Address - Phone:904-241-2653
Mailing Address - Fax:904-246-6312
Practice Address - Street 1:101 FLORIDA BLVD
Practice Address - Street 2:
Practice Address - City:NEPTUNE BEACH
Practice Address - State:FL
Practice Address - Zip Code:32266-4966
Practice Address - Country:US
Practice Address - Phone:904-241-2653
Practice Address - Fax:904-246-6312
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2010-05-23
Last Update Date:2013-03-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLOS4709207Q00000X, 207QA0401X, 2084P0802X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207QA0401XAllopathic & Osteopathic PhysiciansFamily MedicineAddiction MedicineGroup - Multi-Specialty
No207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Multi-Specialty
No2084P0802XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyAddiction PsychiatryGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL82622OtherBCBS
FL068895900Medicaid
FL82622OtherBCBS