Healthcare Provider Details

I. General information

NPI: 1417169038
Provider Name (Legal Business Name): JEFFREY A TANNER MPT
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 05/04/2007
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

200 HOSPITAL DR
SPENCER WV
25276-1050
US

IV. Provider business mailing address

42 SNYDERS RUN
GANDEEVILLE WV
25243-8704
US

V. Phone/Fax

Practice location:
  • Phone: 304-927-6249
  • Fax: 304-927-6837
Mailing address:
  • Phone: 304-927-6249
  • Fax: 304-927-6837

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code225100000X
TaxonomyPhysical Therapist
License NumberPT001303
License Number StateWV

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: