Provider Demographics
NPI:1578640231
Name:TANNER, TODD FITZGERALD (MD)
Entity Type:Individual
Prefix:DR
First Name:TODD
Middle Name:FITZGERALD
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 1:517 DOCTORS CT
Mailing Address - Street 2:
Mailing Address - City:CHESTER
Mailing Address - State:SC
Mailing Address - Zip Code:29706-8644
Mailing Address - Country:US
Mailing Address - Phone:803-581-2800
Mailing Address - Fax:803-482-4989
Practice Address - Street 1:3601 SW 160TH AVE
Practice Address - Street 2:SUITE 250
Practice Address - City:MIRAMAR
Practice Address - State:FL
Practice Address - Zip Code:33027-6308
Practice Address - Country:US
Practice Address - Phone:877-866-7123
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-11-01
Last Update Date:2014-05-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SC16430208600000X
NC9800713207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
No208600000XAllopathic & Osteopathic PhysiciansSurgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
NC891153PMedicaid
NC891153PMedicaid
2329745Medicare ID - Type Unspecified
NC2254928BMedicare PIN