Healthcare Provider Details

I. General information

NPI: 1992710750
Provider Name (Legal Business Name): TMC TANNER GYNECOLOGY INC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 07/30/2006
Last Update Date: 05/14/2008
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

690 DALLAS HWY SUITE 301
VILLA RICA GA
30180-1264
US

IV. Provider business mailing address

119 AMBULANCE DR SUITE 202
CARROLLTON GA
30117-3857
US

V. Phone/Fax

Practice location:
  • Phone: 770-456-3850
  • Fax: 770-456-3826
Mailing address:
  • Phone:
  • Fax: 770-838-8922

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207V00000X
TaxonomyObstetrics & Gynecology Physician
License Number
License Number State

VIII. Authorized Official

Name: DEBBI MACALUSO-PEARE
Title or Position: CFO
Credential:
Phone: 770-838-8554