Basic Information
| Provider Information | |||||||||
| NPI: | 1295744324 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | TANNER | ||||||||
| FirstName: | EDWARD | ||||||||
| MiddleName: | C | ||||||||
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| Credential: | MD | ||||||||
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| Mailing Information | |||||||||
| Address1: | 1445 PORTLAND AVE | ||||||||
| Address2: | SUITE 210 | ||||||||
| City: | ROCHESTER | ||||||||
| State: | NY | ||||||||
| PostalCode: | 14621 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5852662583 | ||||||||
| FaxNumber: | 5852665363 | ||||||||
| Practice Location | |||||||||
| Address1: | 1445 PORTLAND AVE | ||||||||
| Address2: | SUITE 210 | ||||||||
| City: | ROCHESTER | ||||||||
| State: | NY | ||||||||
| PostalCode: | 14621 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5852662583 | ||||||||
| FaxNumber: | 5852665363 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 08/07/2006 | ||||||||
| LastUpdateDate: | 06/04/2009 | ||||||||
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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 | 207X00000X | 1402751 | NY | Y | Allopathic & Osteopathic Physicians | Orthopaedic Surgery |
ID Information
| ID | Type | State | Issuer | Description | P010140275 | 01 | BLUE CHOICE | OTHER | 00593559 | 05 | NY | MEDICAID | 102336C4 | 01 | PREFERRED CARE | OTHER |