Basic Information
| Provider Information | |||||||||
| NPI: | 1992710750 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | TMC TANNER GYNECOLOGY INC | ||||||||
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| OtherOrganizationName: | VILLA RICA OBSTETRICS AND GYNECOLOGY | ||||||||
| OtherOrganizationType: | 3 | ||||||||
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| Mailing Information | |||||||||
| Address1: | 119 AMBULANCE DR | ||||||||
| Address2: | SUITE 202 | ||||||||
| City: | CARROLLTON | ||||||||
| State: | GA | ||||||||
| PostalCode: | 301173857 | ||||||||
| CountryCode: | US | ||||||||
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| FaxNumber: | 7708388922 | ||||||||
| Practice Location | |||||||||
| Address1: | 690 DALLAS HWY | ||||||||
| Address2: | SUITE 301 | ||||||||
| City: | VILLA RICA | ||||||||
| State: | GA | ||||||||
| PostalCode: | 301801264 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7704563850 | ||||||||
| FaxNumber: | 7704563826 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 07/30/2006 | ||||||||
| LastUpdateDate: | 05/14/2008 | ||||||||
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| AuthorizedOfficialLastName: | MACALUSO-PEARE | ||||||||
| AuthorizedOfficialFirstName: | DEBBI | ||||||||
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| AuthorizedOfficialTitleorPosition: | CFO | ||||||||
| AuthorizedOfficialTelephone: | 7708388554 | ||||||||
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| IsOrganizationSubpart: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207V00000X | Y | 193400000X SINGLE SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Obstetrics & Gynecology |
No ID Information.