Provider Demographics
NPI:1790756153
Name:TANNER, GERALD E (MD)
Entity Type:Individual
Prefix:DR
First Name:GERALD
Middle Name:E
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 1:390 OLD GARDEN VALLEY RD
Mailing Address - Street 2:
Mailing Address - City:ROSEBURG
Mailing Address - State:OR
Mailing Address - Zip Code:97471-9544
Mailing Address - Country:US
Mailing Address - Phone:503-475-5811
Mailing Address - Fax:
Practice Address - Street 1:3181 SW SAM JACKSON PARK RD
Practice Address - Street 2:
Practice Address - City:PORTLAND
Practice Address - State:OR
Practice Address - Zip Code:97239-3011
Practice Address - Country:US
Practice Address - Phone:503-494-7641
Practice Address - Fax:503-494-3092
Is Sole Proprietor?:No
Enumeration Date:2006-02-01
Last Update Date:2014-03-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ORMD08877207L00000X
WI46747-20207L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207L00000XAllopathic & Osteopathic PhysiciansAnesthesiology
Provider Identifiers
StateIdentifier IDID TypeIssuer
OR241141Medicaid
OR241141Medicaid
ORC93904Medicare UPIN