Healthcare Provider Details

I. General information

NPI: 1376881870
Provider Name (Legal Business Name): TANNER MEDICAL CLINIC LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 01/18/2013
Last Update Date: 05/23/2023
Certification Date: 05/23/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

20104 SWANNER BLVD SUITE 4
TANNER AL
35671-3651
US

IV. Provider business mailing address

20104 SWANNER BLVD
TANNER AL
35671-3651
US

V. Phone/Fax

Practice location:
  • Phone: 256-686-3334
  • Fax: 256-686-3339
Mailing address:
  • Phone: 256-686-3334
  • Fax: 256-686-3339

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code363L00000X
TaxonomyNurse Practitioner
License Number
License Number State
# 3
Primary TaxonomyY
Taxonomy Code261QR1300X
TaxonomyRural Health Clinic/Center
License Number
License Number StateAL

VIII. Authorized Official

Name: MICHELLE SLOAN GRAHAM
Title or Position: VP OF OPERATIONS
Credential: FNP-C
Phone: 256-432-2822