MEDICARE: MR. JAMES TANNER

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	225100000X	Physical Therapist	PT1316	ID

General Provider Information

NPI Number	:	1023000411
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MR. JAMES TANNER

Provider Business Mailing Address
First Line	:	341 MDG 7300 NORTH PERIMETER ROAD
Second Line	:
City	:	MALMSTROM AFB
State	:	MT
Zip	:	59402-6780
Country	:	US
Telephone Number	:	406-731-4456
Fax Number	:

Provider Business Practice Location Address
First Line	:	341 MDG 7300 NORTH PERIMETER ROAD
Second Line	:
City	:	MALMSTROM AFB
State	:	MT
Zip	:	59402-6780
Country	:	US
Telephone Number	:	406-731-4456
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	08/22/2005
Last Update Date	:	07/17/2012

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