Healthcare Provider Details

I. General information

NPI: 1578740668
Provider Name (Legal Business Name): JUSTIN TANNIR MD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 01/30/2008
Last Update Date: 05/28/2020
Certification Date: 05/28/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

5199 N ROYAL DR
TRAVERSE CITY MI
49684-9201
US

IV. Provider business mailing address

1560 E. MAPLE RD. SUITE 400-CREDENTIALING
TROY MI
48083
US

V. Phone/Fax

Practice location:
  • Phone: 231-935-8101
  • Fax: 231-346-5926
Mailing address:
  • Phone: 313-577-8900
  • Fax: 313-577-0700

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207W00000X
TaxonomyOphthalmology Physician
License Number4301092763
License Number StateMI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: