Provider Demographics
NPI:1376881870
Name:TANNER MEDICAL CLINIC LLC
Entity type:Organization
Organization Name:TANNER MEDICAL CLINIC LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:VP OF OPERATIONS
Authorized Official - Prefix:
Authorized Official - First Name:MICHELLE
Authorized Official - Middle Name:SLOAN
Authorized Official - Last Name:GRAHAM
Authorized Official - Suffix:
Authorized Official - Credentials:FNP-C
Authorized Official - Phone:256-432-2822
Mailing Address - Street 1:20104 SWANNER BLVD
Mailing Address - Street 2:
Mailing Address - City:TANNER
Mailing Address - State:AL
Mailing Address - Zip Code:35671-3651
Mailing Address - Country:US
Mailing Address - Phone:256-686-3334
Mailing Address - Fax:256-686-3339
Practice Address - Street 1:20104 SWANNER BLVD
Practice Address - Street 2:SUITE 4
Practice Address - City:TANNER
Practice Address - State:AL
Practice Address - Zip Code:35671-3651
Practice Address - Country:US
Practice Address - Phone:256-686-3334
Practice Address - Fax:256-686-3339
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2013-01-18
Last Update Date:2023-05-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
207Q00000X, 363L00000X
AL261QR1300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes261QR1300XAmbulatory Health Care FacilitiesClinic/CenterRural HealthGroup - Single Specialty
No207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Single Specialty
No363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
AL159174Medicaid