Healthcare Provider Details

I. General information

NPI: 1558300038
Provider Name (Legal Business Name): ROBERT W TANNEY D.O.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/06/2006
Last Update Date: 10/13/2020
Certification Date: 10/13/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

650 W LAKE COOK RD
BUFFALO GROVE IL
60089-2082
US

IV. Provider business mailing address

650 W LAKE COOK RD
BUFFALO GROVE IL
60089-2082
US

V. Phone/Fax

Practice location:
  • Phone: 847-520-9424
  • Fax: 847-520-9479
Mailing address:
  • Phone: 847-520-9424
  • Fax: 847-520-9479

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207QA0505X
TaxonomyAdult Medicine Physician
License Number036073747
License Number StateIL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: