MEDICARE: DAVID EDWARD TANNEHILL D.O.

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	207R00000X	Internal Medicine Physician	2006025332	MO
2	207R00000X	Internal Medicine Physician	O-1735	ID

General Provider Information

NPI Number	:	1750591053
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	DAVID EDWARD TANNEHILL D.O.

Provider Business Mailing Address
First Line	:	1662 SAN MIGUEL LN
Second Line	:
City	:	FENTON
State	:	MO
Zip	:	63026-3244
Country	:	US
Telephone Number	:	636-529-0048
Fax Number	:

Provider Business Practice Location Address
First Line	:	621 S NEW BALLAS RD
Second Line	:
City	:	CREVE COEUR
State	:	MO
Zip	:	63141-8232
Country	:	US
Telephone Number	:	314-251-5834
Fax Number	:

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

Provider Enumeration Date	:	05/23/2007
Last Update Date	:	09/20/2022

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