Provider Demographics
NPI:1205259777
Name:JUSTIN TANNER MD LLC
Entity type:Organization
Organization Name:JUSTIN TANNER MD LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OFFICIAL
Authorized Official - Prefix:DR
Authorized Official - First Name:JUSTIN
Authorized Official - Middle Name:
Authorized Official - Last Name:TANNER
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:303-906-4201
Mailing Address - Street 1:59724 MANCOS LN
Mailing Address - Street 2:
Mailing Address - City:MONTROSE
Mailing Address - State:CO
Mailing Address - Zip Code:81403-7375
Mailing Address - Country:US
Mailing Address - Phone:303-906-4201
Mailing Address - Fax:
Practice Address - Street 1:59724 MANCOS LN
Practice Address - Street 2:
Practice Address - City:MONTROSE
Practice Address - State:CO
Practice Address - Zip Code:81403-7375
Practice Address - Country:US
Practice Address - Phone:303-906-4201
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2014-02-03
Last Update Date:2014-02-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal MedicineGroup - Single Specialty