Provider Demographics
NPI:1720091390
Name:TYNER, THOMAS G (CRNA)
Entity Type:Individual
Prefix:
First Name:THOMAS
Middle Name:G
Last Name:TYNER
Suffix:
Gender:M
Credentials:CRNA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 1245
Mailing Address - Street 2:
Mailing Address - City:ORANGEBURG
Mailing Address - State:SC
Mailing Address - Zip Code:29116-1245
Mailing Address - Country:US
Mailing Address - Phone:803-395-4499
Mailing Address - Fax:803-395-4480
Practice Address - Street 1:3000 ST MATTHEWS RD
Practice Address - Street 2:
Practice Address - City:ORANGEBURG
Practice Address - State:SC
Practice Address - Zip Code:29118-1442
Practice Address - Country:US
Practice Address - Phone:803-395-2200
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-08-14
Last Update Date:2008-04-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SC3012367500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes367500000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Anesthetist, Certified Registered
Provider Identifiers
StateIdentifier IDID TypeIssuer
SC576008010015OtherTRICARE
MEMM5083OtherMEDICARE PART B
SCAN1516Medicaid
SC576008010009OtherBCBS
LA5S867OtherMEDICAE PART B
SC576008010006OtherBLUE CHOICE
SC000000194021OtherUNISON
SC20056087OtherFIRST CHOICE
SCQ342577386Medicare PIN
SC000000194021OtherUNISON
SCAN1516Medicaid