Provider Demographics
NPI:1598875973
Name:TANNER, GREGORY C (MD)
Entity Type:Individual
Prefix:
First Name:GREGORY
Middle Name:C
Last Name:TANNER
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Credentials:
Mailing Address - Street 1:41 NORTHRIDGE WAY
Mailing Address - Street 2:
Mailing Address - City:SANDY
Mailing Address - State:UT
Mailing Address - Zip Code:84092-4906
Mailing Address - Country:US
Mailing Address - Phone:801-963-1880
Mailing Address - Fax:801-963-1886
Practice Address - Street 1:9600 S 1300 E
Practice Address - Street 2:STE 305
Practice Address - City:SANDY
Practice Address - State:UT
Practice Address - Zip Code:84094-3766
Practice Address - Country:US
Practice Address - Phone:801-963-1880
Practice Address - Fax:801-963-1886
Is Sole Proprietor?:Yes
Enumeration Date:2006-08-30
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
UT157109-1205207VG0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207VG0400XAllopathic & Osteopathic PhysiciansObstetrics & GynecologyGynecology
Provider Identifiers
StateIdentifier IDID TypeIssuer
UTD07795Medicare UPIN