Provider Demographics
NPI:1972503829
Name:SELLERS-HANNIBAL, TANYA R (DPM)
Entity Type:Individual
Prefix:
First Name:TANYA
Middle Name:R
Last Name:SELLERS-HANNIBAL
Suffix:
Gender:F
Credentials:DPM
Other - Prefix:
Other - First Name:TANYA
Other - Middle Name:ROCHELLE
Other - Last Name:SELLERS
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:DPM
Mailing Address - Street 1:10085 RED RUN BLVD
Mailing Address - Street 2:SUITE 305
Mailing Address - City:OWINGS MILLS
Mailing Address - State:MD
Mailing Address - Zip Code:21117-4836
Mailing Address - Country:US
Mailing Address - Phone:410-581-8331
Mailing Address - Fax:410-581-8332
Practice Address - Street 1:10085 RED RUN BLVD
Practice Address - Street 2:SUITE 305
Practice Address - City:OWINGS MILLS
Practice Address - State:MD
Practice Address - Zip Code:21117-4836
Practice Address - Country:US
Practice Address - Phone:410-581-8331
Practice Address - Fax:410-581-8332
Is Sole Proprietor?:No
Enumeration Date:2005-07-21
Last Update Date:2017-07-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MD01173213ES0131X, 213E00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes213E00000XPodiatric Medicine & Surgery Service ProvidersPodiatrist
No213ES0131XPodiatric Medicine & Surgery Service ProvidersPodiatristFoot Surgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
MD119128400Medicaid
MDT366OtherBCBS
MDU47525Medicare UPIN
MD1017000001Medicare NSC
MDT366OtherBCBS