Provider Demographics
NPI:1295744324
Name:TANNER, EDWARD C (MD)
Entity type:Individual
Prefix:
First Name:EDWARD
Middle Name:C
Last Name:TANNER
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1445 PORTLAND AVE
Mailing Address - Street 2:SUITE 210
Mailing Address - City:ROCHESTER
Mailing Address - State:NY
Mailing Address - Zip Code:14621
Mailing Address - Country:US
Mailing Address - Phone:585-266-2583
Mailing Address - Fax:585-266-5363
Practice Address - Street 1:1445 PORTLAND AVE
Practice Address - Street 2:SUITE 210
Practice Address - City:ROCHESTER
Practice Address - State:NY
Practice Address - Zip Code:14621
Practice Address - Country:US
Practice Address - Phone:585-266-2583
Practice Address - Fax:585-266-5363
Is Sole Proprietor?:No
Enumeration Date:2006-08-07
Last Update Date:2009-06-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY1402751207X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207X00000XAllopathic & Osteopathic PhysiciansOrthopaedic Surgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
P010140275OtherBLUE CHOICE
NY00593559Medicaid
102336C4OtherPREFERRED CARE
P010140275OtherBLUE CHOICE
D10735Medicare UPIN
NYJ400003134Medicare PIN