MEDICARE: TARA NICOLE GRESHAM HS/SF-IDC

Medicare Provider Information

Scope of Practice

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

#	Taxonomy Code	Taxonomy
1	171000000X	Military Health Care Provider
2	247200000X	Other Technician
3	1710I1002X	Independent Duty Corpsman
4	146N00000X	Basic Emergency Medical Technician

General Provider Information

NPI Number	:	1679601413
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	TARA NICOLE GRESHAM HS/SF-IDC

Provider Business Mailing Address
First Line	:	10565 COUNTY ROAD 1
Second Line	:
City	:	FAIRHOPE
State	:	AL
Zip	:	36532-5932
Country	:	US
Telephone Number	:	727-593-4453
Fax Number	:

Provider Business Practice Location Address
First Line	:	1050 REGISTER ST
Second Line	:
City	:	CHARLESTON
State	:	SC
Zip	:	29405-2421
Country	:	US
Telephone Number	:	843-740-3147
Fax Number	:

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

Provider Enumeration Date	:	03/02/2007
Last Update Date	:	01/20/2024

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