Provider Demographics
NPI:1588026181
Name:TANNER, MICHAEL S (MD)
Entity Type:Individual
Prefix:
First Name:MICHAEL
Middle Name:S
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 1:2720 OLD ROSEBUD RD STE 110
Mailing Address - Street 2:
Mailing Address - City:LEXINGTON
Mailing Address - State:KY
Mailing Address - Zip Code:40509-8005
Mailing Address - Country:US
Mailing Address - Phone:859-373-0300
Mailing Address - Fax:859-373-0024
Practice Address - Street 1:2720 OLD ROSEBUD RD STE 110
Practice Address - Street 2:
Practice Address - City:LEXINGTON
Practice Address - State:KY
Practice Address - Zip Code:40509-8005
Practice Address - Country:US
Practice Address - Phone:859-373-0300
Practice Address - Fax:859-373-0024
Is Sole Proprietor?:No
Enumeration Date:2016-03-23
Last Update Date:2020-08-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KY53534207W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207W00000XAllopathic & Osteopathic PhysiciansOphthalmology
Provider Identifiers
StateIdentifier IDID TypeIssuer
KY7100680850Medicaid