Healthcare Provider Details

I. General information

NPI: 1770391047
Provider Name (Legal Business Name): TANNER BRIDGE CLINIC INC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 12/19/2024
Last Update Date: 05/19/2025
Certification Date: 05/19/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1480 S HIGHWAY 27 STE B
CARROLLTON GA
30117-8901
US

IV. Provider business mailing address

100 GREENWAY BLVD BOX C
CARROLLTON GA
30117-4358
US

V. Phone/Fax

Practice location:
  • Phone: 770-812-5900
  • Fax: 770-812-5584
Mailing address:
  • Phone: 770-838-8710
  • Fax: 770-812-5735

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207P00000X
TaxonomyEmergency Medicine Physician
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License Number
License Number State
# 3
Primary TaxonomyN
Taxonomy Code261QX0100X
TaxonomyOccupational Medicine Clinic/Center
License Number
License Number State

VIII. Authorized Official

Name: CLINT HOFFMAN
Title or Position: SENIOR VP TANNER MEDICAL GROUP
Credential:
Phone: 770-812-5304