Basic Information
| Provider Information | |||||||||
| NPI: | 1144284498 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | TANNER | ||||||||
| FirstName: | TIMOTHY | ||||||||
| MiddleName: | H | ||||||||
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| Credential: | MD | ||||||||
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| Mailing Information | |||||||||
| Address1: | 165 SHERMAN DR | ||||||||
| Address2: | |||||||||
| City: | ST JOHNSBURY | ||||||||
| State: | VT | ||||||||
| PostalCode: | 058199811 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8027489405 | ||||||||
| FaxNumber: | 8027484540 | ||||||||
| Practice Location | |||||||||
| Address1: | 26 CEDAR LN | ||||||||
| Address2: | |||||||||
| City: | DANVILLE | ||||||||
| State: | VT | ||||||||
| PostalCode: | 058289751 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8026842275 | ||||||||
| FaxNumber: | 8026843839 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 04/13/2006 | ||||||||
| LastUpdateDate: | 07/16/2010 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207R00000X | 0420008723 | VT | Y | Allopathic & Osteopathic Physicians | Internal Medicine | 208000000X | 0420008723 | VT | N | Allopathic & Osteopathic Physicians | Pediatrics |
ID Information
| ID | Type | State | Issuer | Description | 0VN0612 | 05 | VT | MEDICAID |