Basic Information
| Provider Information | |||||||||
| NPI: | 1255899092 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | TANNER PRIMARY CARE OF ROANOKE INC | ||||||||
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| Mailing Information | |||||||||
| Address1: | 706 DIXIE ST STE 220 | ||||||||
| Address2: | |||||||||
| City: | CARROLLTON | ||||||||
| State: | GA | ||||||||
| PostalCode: | 301173889 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7708388710 | ||||||||
| FaxNumber: | 7708125735 | ||||||||
| Practice Location | |||||||||
| Address1: | 965 HIGHWAY 431 | ||||||||
| Address2: | |||||||||
| City: | ROANOKE | ||||||||
| State: | AL | ||||||||
| PostalCode: | 362747329 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3348632141 | ||||||||
| FaxNumber: | 3348638733 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 03/12/2019 | ||||||||
| LastUpdateDate: | 04/28/2021 | ||||||||
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| AuthorizedOfficialLastName: | FOX | ||||||||
| AuthorizedOfficialFirstName: | SUSAN | ||||||||
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| AuthorizedOfficialTitleorPosition: | SENIOR VP OF OPERATIONS | ||||||||
| AuthorizedOfficialTelephone: | 7708388302 | ||||||||
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| IsOrganizationSubpart: | N | ||||||||
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| NPICertificationDate: | 04/28/2021 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207Q00000X | N | 193400000X SINGLE SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Family Medicine | 261QR1300X | Y | Ambulatory Health Care Facilities | Clinic/Center | Rural Health |
No ID Information.