Provider Demographics
NPI:1790799740
Name:TANNER, LYDIA CHANEY (MD)
Entity Type:Individual
Prefix:DR
First Name:LYDIA
Middle Name:CHANEY
Last Name:TANNER
Suffix:
Gender:F
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 1377
Mailing Address - Street 2:
Mailing Address - City:DOUGLAS
Mailing Address - State:GA
Mailing Address - Zip Code:31534-1377
Mailing Address - Country:US
Mailing Address - Phone:912-384-1477
Mailing Address - Fax:912-384-1470
Practice Address - Street 1:100 DOCTORS DR STE G
Practice Address - Street 2:
Practice Address - City:DOUGLAS
Practice Address - State:GA
Practice Address - Zip Code:31533-2211
Practice Address - Country:US
Practice Address - Phone:912-384-6186
Practice Address - Fax:912-384-6187
Is Sole Proprietor?:No
Enumeration Date:2006-07-27
Last Update Date:2022-07-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA53885207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA366115747BMedicaid
GA053885OtherMEDICAL LICENSE
GA366115747AMedicaid
GA08BBRCRMedicare ID - Type Unspecified
GA366115747AMedicaid