Basic Information
| Provider Information | |||||||||
| NPI: | 1801883780 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | TANNER MEDICAL CENTER, INC | ||||||||
| LastName: | |||||||||
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| OtherOrganizationName: | TANNER HEALTH SYSTEM | ||||||||
| OtherOrganizationType: | 3 | ||||||||
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| Mailing Information | |||||||||
| Address1: | 705 DIXIE ST | ||||||||
| Address2: | |||||||||
| City: | CARROLLTON | ||||||||
| State: | GA | ||||||||
| PostalCode: | 301173818 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7708369666 | ||||||||
| FaxNumber: | 7708369897 | ||||||||
| Practice Location | |||||||||
| Address1: | 705 DIXIE ST | ||||||||
| Address2: | |||||||||
| City: | CARROLLTON | ||||||||
| State: | GA | ||||||||
| PostalCode: | 301173818 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7708369666 | ||||||||
| FaxNumber: | 7708369897 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 10/05/2005 | ||||||||
| LastUpdateDate: | 08/22/2020 | ||||||||
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| AuthorizedOfficialLastName: | SHERSETH | ||||||||
| AuthorizedOfficialFirstName: | LEE | ||||||||
| AuthorizedOfficialMiddleName: | C. | ||||||||
| AuthorizedOfficialTitleorPosition: | CEO | ||||||||
| AuthorizedOfficialTelephone: | 7708369697 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialNamePrefix: | MR. | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 282N00000X | 022-426 | GA | Y | Hospitals | General Acute Care Hospital |
ID Information
| ID | Type | State | Issuer | Description | 00001867-A | 05 | GA | MEDICAID |