Provider Demographics
NPI:1871502260
Name:TANNER MEDICAL CENTER, INC
Entity Type:Organization
Organization Name:TANNER MEDICAL CENTER, INC
Other - Org Name:TANNER MEDICAL CENTER CARROLLTON BH
Other - Org Type:Other Name
Authorized Official - Title/Position:CFO
Authorized Official - Prefix:MR
Authorized Official - First Name:LEE
Authorized Official - Middle Name:C
Authorized Official - Last Name:SHERSETH
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:770-836-9697
Mailing Address - Street 1:705 DIXIE ST
Mailing Address - Street 2:
Mailing Address - City:CARROLLTON
Mailing Address - State:GA
Mailing Address - Zip Code:30117-3818
Mailing Address - Country:US
Mailing Address - Phone:770-836-9697
Mailing Address - Fax:770-836-9897
Practice Address - Street 1:523 DIXIE ST
Practice Address - Street 2:
Practice Address - City:CARROLLTON
Practice Address - State:GA
Practice Address - Zip Code:30117-3870
Practice Address - Country:US
Practice Address - Phone:770-836-9697
Practice Address - Fax:770-836-9897
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:TANNER MEDICAL CENTER
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2006-08-05
Last Update Date:2010-02-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GANOT REQUIRED101Y00000X
GA022-426251S00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes251S00000XAgenciesCommunity/Behavioral Health
No101Y00000XBehavioral Health & Social Service ProvidersCounselorGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA300027104AOtherMEDICAID PAYEE IDENTIFICATION NUMBER
GA296667723AMedicaid