Provider Demographics
NPI:1649240649
Name:TANNER, BENJAMIN D (MD)
Entity Type:Individual
Prefix:
First Name:BENJAMIN
Middle Name:D
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:PO BOX 776351
Mailing Address - Street 2:
Mailing Address - City:CHICAGO
Mailing Address - State:IL
Mailing Address - Zip Code:60677-6351
Mailing Address - Country:US
Mailing Address - Phone:502-588-9490
Mailing Address - Fax:502-272-5116
Practice Address - Street 1:1000 DUPONT RD
Practice Address - Street 2:
Practice Address - City:LOUISVILLE
Practice Address - State:KY
Practice Address - Zip Code:40207-4611
Practice Address - Country:US
Practice Address - Phone:502-889-6405
Practice Address - Fax:502-899-6407
Is Sole Proprietor?:No
Enumeration Date:2006-01-24
Last Update Date:2021-01-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KY33097208600000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208600000XAllopathic & Osteopathic PhysiciansSurgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
KY110964OtherSIHO - NHWMS
IN200518160Medicaid
KY3945283OtherCIGNA - NHWMS
KY50027318OtherPASSPORT - NHWMS
KY64100811Medicaid
KY000000642238OtherANTHEM - NHWMS
KY000052153COtherHUMANA - NHWMS
KY3764333000OtherPASSPORT ADVANTAGE - NHWMS
KY50006995OtherPASSPORT
IN200518160Medicaid
KYK079881Medicare PIN
IN265130RRRMedicare PIN
KY000052153COtherHUMANA - NHWMS
KY64100811Medicaid
KY00533205Medicare PIN
IN859910G4Medicare PIN