Healthcare Provider Details

I. General information

NPI: 1457539082
Provider Name (Legal Business Name): JOHN M TENNIS M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 02/06/2008
Last Update Date: 02/06/2008
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1027A EDGEFIELD ST
GREENWOOD SC
29646-3205
US

IV. Provider business mailing address

1027A EDGEFIELD ST
GREENWOOD SC
29646-3205
US

V. Phone/Fax

Practice location:
  • Phone: 864-227-9708
  • Fax: 864-229-5542
Mailing address:
  • Phone: 864-227-9708
  • Fax: 864-229-5542

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207QB0002X
TaxonomyObesity Medicine (Family Medicine) Physician
License Number10951
License Number StateSC

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: