Healthcare Provider Details

I. General information

NPI: 1144284498
Provider Name (Legal Business Name): TIMOTHY H TANNER MD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 04/13/2006
Last Update Date: 07/16/2010
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

26 CEDAR LN
DANVILLE VT
05828-9751
US

IV. Provider business mailing address

165 SHERMAN DR
ST JOHNSBURY VT
05819-9811
US

V. Phone/Fax

Practice location:
  • Phone: 802-684-2275
  • Fax: 802-684-3839
Mailing address:
  • Phone: 802-748-9405
  • Fax: 802-748-4540

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207R00000X
TaxonomyInternal Medicine Physician
License Number0420008723
License Number StateVT
# 2
Primary TaxonomyN
Taxonomy Code208000000X
TaxonomyPediatrics Physician
License Number0420008723
License Number StateVT

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: