Provider Demographics
NPI:1396979787
Name:TANNER MEDICAL GROUP INC
Entity type:Organization
Organization Name:TANNER MEDICAL GROUP INC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:SR VP
Authorized Official - Prefix:
Authorized Official - First Name:CLINT
Authorized Official - Middle Name:
Authorized Official - Last Name:HOFFMAN
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:770-812-8845
Mailing Address - Street 1:100 GREENWAY BLVD FL 2
Mailing Address - Street 2:
Mailing Address - City:CARROLLTON
Mailing Address - State:GA
Mailing Address - Zip Code:30117-4338
Mailing Address - Country:US
Mailing Address - Phone:770-838-8710
Mailing Address - Fax:770-812-5735
Practice Address - Street 1:100 GREENWAY BLVD FL 2
Practice Address - Street 2:
Practice Address - City:CARROLLTON
Practice Address - State:GA
Practice Address - Zip Code:30117-4338
Practice Address - Country:US
Practice Address - Phone:770-838-8710
Practice Address - Fax:770-812-5735
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2009-05-13
Last Update Date:2024-02-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
204E00000X, 207Q00000X, 207R00000X, 207RG0100X, 207RP1001X, 207V00000X, 208000000X, 2084N0400X, 207RI0011X, 207RI0200X, 2084P0800X, 208VP0000X, 208D00000X, 207RC0000X
GA2086S0129X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207RC0000XAllopathic & Osteopathic PhysiciansInternal MedicineCardiovascular DiseaseGroup - Multi-Specialty
No204E00000XAllopathic & Osteopathic PhysiciansOral & Maxillofacial SurgeryGroup - Multi-Specialty
No207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Multi-Specialty
No207R00000XAllopathic & Osteopathic PhysiciansInternal MedicineGroup - Multi-Specialty
No207RG0100XAllopathic & Osteopathic PhysiciansInternal MedicineGastroenterologyGroup - Multi-Specialty
No207RP1001XAllopathic & Osteopathic PhysiciansInternal MedicinePulmonary DiseaseGroup - Multi-Specialty
No207V00000XAllopathic & Osteopathic PhysiciansObstetrics & GynecologyGroup - Multi-Specialty
No208000000XAllopathic & Osteopathic PhysiciansPediatricsGroup - Multi-Specialty
No2084N0400XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyNeurologyGroup - Multi-Specialty
No207RI0011XAllopathic & Osteopathic PhysiciansInternal MedicineInterventional CardiologyGroup - Multi-Specialty
No207RI0200XAllopathic & Osteopathic PhysiciansInternal MedicineInfectious DiseaseGroup - Multi-Specialty
No2084P0800XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyPsychiatryGroup - Multi-Specialty
No208VP0000XAllopathic & Osteopathic PhysiciansPain MedicinePain MedicineGroup - Multi-Specialty
No2086S0129XAllopathic & Osteopathic PhysiciansSurgeryVascular SurgeryGroup - Multi-Specialty
No208D00000XAllopathic & Osteopathic PhysiciansGeneral PracticeGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA202G707301OtherMEDICARE PTAN