Healthcare Provider Details

I. General information

NPI: 1376620575
Provider Name (Legal Business Name): TANNER FRED LANG MD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 11/01/2006
Last Update Date: 07/21/2022
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

7807 N LAKE DR
FOX POINT WI
53217-2911
US

IV. Provider business mailing address

7807 N LAKE DR
FOX POINT WI
53217-2911
US

V. Phone/Fax

Practice location:
  • Phone: 262-347-9495
  • Fax:
Mailing address:
  • Phone: 262-347-9495
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207L00000X
TaxonomyAnesthesiology Physician
License Number49047-020
License Number StateWI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: