Provider Demographics
NPI:1629050067
Name:TANNER, REBECCA I (MD)
Entity Type:Individual
Prefix:
First Name:REBECCA
Middle Name:I
Last Name:TANNER
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:REBECCA
Other - Middle Name:IRENE
Other - Last Name:POLLAK
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:MD
Mailing Address - Street 1:PO BOX 271220
Mailing Address - Street 2:
Mailing Address - City:SALT LAKE CITY
Mailing Address - State:UT
Mailing Address - Zip Code:84127-1220
Mailing Address - Country:US
Mailing Address - Phone:801-736-0110
Mailing Address - Fax:801-366-9883
Practice Address - Street 1:1160 E 3900 S
Practice Address - Street 2:SUITE G200
Practice Address - City:SALT LAKE CITY
Practice Address - State:UT
Practice Address - Zip Code:84124-1202
Practice Address - Country:US
Practice Address - Phone:801-268-7766
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2005-11-18
Last Update Date:2010-09-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
UT3258511205207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
UTPR67234Medicaid
UT5778501Medicare ID - Type Unspecified
UTPR67234Medicaid