Provider Demographics
NPI:1881645513
Name:TANNER, TINA LOUISE (MD)
Entity Type:Individual
Prefix:
First Name:TINA
Middle Name:LOUISE
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 1848
Mailing Address - Street 2:
Mailing Address - City:MUSKEGON
Mailing Address - State:MI
Mailing Address - Zip Code:49443-1848
Mailing Address - Country:US
Mailing Address - Phone:231-672-3333
Mailing Address - Fax:231-672-3465
Practice Address - Street 1:2006 HOLTON RD
Practice Address - Street 2:
Practice Address - City:MUSKEGON
Practice Address - State:MI
Practice Address - Zip Code:49445-1505
Practice Address - Country:US
Practice Address - Phone:231-672-3333
Practice Address - Fax:231-672-3465
Is Sole Proprietor?:No
Enumeration Date:2006-05-15
Last Update Date:2019-02-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI4301070365207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
MIN28430OtherMEDICARE PTAN
MI4467690Medicaid
MIH18908Medicare UPIN