Healthcare Provider Details

I. General information

NPI: 1790756153
Provider Name (Legal Business Name): GERALD E TANNER MD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 02/01/2006
Last Update Date: 03/26/2014
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3181 SW SAM JACKSON PARK RD
PORTLAND OR
97239-3011
US

IV. Provider business mailing address

390 OLD GARDEN VALLEY RD
ROSEBURG OR
97471-9544
US

V. Phone/Fax

Practice location:
  • Phone: 503-494-7641
  • Fax: 503-494-3092
Mailing address:
  • Phone: 503-475-5811
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code207L00000X
TaxonomyAnesthesiology Physician
License NumberMD08877
License Number StateOR
# 2
Primary TaxonomyY
Taxonomy Code207L00000X
TaxonomyAnesthesiology Physician
License Number46747-20
License Number StateWI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: