Provider Demographics
NPI:1619033651
Name:TANNER, ERNEST (DC)
Entity Type:Individual
Prefix:DR
First Name:ERNEST
Middle Name:
Last Name:TANNER
Suffix:
Gender:M
Credentials:DC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:215 E SECOND ST
Mailing Address - Street 2:
Mailing Address - City:BEARDSTOWN
Mailing Address - State:IL
Mailing Address - Zip Code:62618-1222
Mailing Address - Country:US
Mailing Address - Phone:217-323-3116
Mailing Address - Fax:217-323-3711
Practice Address - Street 1:215 E SECOND ST
Practice Address - Street 2:
Practice Address - City:BEARDSTOWN
Practice Address - State:IL
Practice Address - Zip Code:62618-1222
Practice Address - Country:US
Practice Address - Phone:217-323-3116
Practice Address - Fax:217-323-3711
Is Sole Proprietor?:No
Enumeration Date:2006-12-27
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL0038008378111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes111N00000XChiropractic ProvidersChiropractor
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL0000921966OtherBCBS
IL0000921966OtherBCBS
406790Medicare ID - Type Unspecified