1649240649 NPI number — BENJAMIN D TANNER MD

Table of content: BENJAMIN D TANNER MD (NPI 1649240649)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1649240649 NPI number — BENJAMIN D TANNER MD

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
TANNER
Provider First Name:
BENJAMIN
Provider Middle Name:
D
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
MD
Provider Gender Code:
M

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1649240649
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
01/22/2021
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
PO BOX 776351
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
CHICAGO
Provider Business Mailing Address State Name:
IL
Provider Business Mailing Address Postal Code:
60677-6351
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
502-588-9490
Provider Business Mailing Address Fax Number:
502-272-5116

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
1000 DUPONT RD
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
LOUISVILLE
Provider Business Practice Location Address State Name:
KY
Provider Business Practice Location Address Postal Code:
40207-4611
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
502-889-6405
Provider Business Practice Location Address Fax Number:
502-899-6407
Provider Enumeration Date:
01/24/2006

Additional Information

Authorized Official

Authorized Official Last Name:
Authorized Official First Name:
Authorized Official Middle Name:
Authorized Official Title or Position:
Authorized Official Telephone Number:

Provider Taxonomy Codes

  • Taxonomy code: 208600000X , with the licence number:  33097 , registered in the state of KY ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)

  • Identifier: 110964 . This is a "SIHO - NHWMS" identifier , issued by the state of ( KY ) . This identifiers is of the category "OTHER".
  • Identifier: 200518160 , issued by the state of ( IN ) . This identifiers is of the category "MEDICAID".
  • Identifier: 3945283 . This is a "CIGNA - NHWMS" identifier , issued by the state of ( KY ) . This identifiers is of the category "OTHER".
  • Identifier: 50027318 . This is a "PASSPORT - NHWMS" identifier , issued by the state of ( KY ) . This identifiers is of the category "OTHER".
  • Identifier: 64100811 , issued by the state of ( KY ) . This identifiers is of the category "MEDICAID".
  • Identifier: 000000642238 . This is a "ANTHEM - NHWMS" identifier , issued by the state of ( KY ) . This identifiers is of the category "OTHER".
  • Identifier: 000052153C . This is a "HUMANA - NHWMS" identifier , issued by the state of ( KY ) . This identifiers is of the category "OTHER".
  • Identifier: 3764333000 . This is a "PASSPORT ADVANTAGE - NHWMS" identifier , issued by the state of ( KY ) . This identifiers is of the category "OTHER".
  • Identifier: 50006995 . This is a "PASSPORT" identifier , issued by the state of ( KY ) . This identifiers is of the category "OTHER".




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