NPIMap

Organization Active NPI

Tanner Primary Care of Roanoke Inc

  • Rural Health Clinic/Center
  • Roanoke, AL
National Provider Identifier
1255899092
Registry record updated Feb 29, 2024
On this page

Key facts

NPPES NPI Registry
Primary specialty
Rural Health Clinic/CenterTaxonomy code 261QR1300X
Legal business name
TANNER PRIMARY CARE OF ROANOKE INC
Practice address
965 Highway 431
Roanoke, AL 36274-7329
Phone
(334) 863-2141
Fax
(334) 863-8733
NPI assigned
Mar 12, 2019
Last updated
Feb 29, 2024By the provider in NPPES
Organization subpart
No

NPPES NPI Registry

Updated by the provider on Feb 29, 2024

Registry information is reported by the provider to CMS and is not verified. About this source

Authorized official

Name
Clint Hoffman
Title
Sr VP
Phone
(770) 838-8302

Specialties & licenses 2

Specialty (taxonomy)CodeLicenseStatePrimary
Family Medicine PhysicianGroup: 193400000X SINGLE SPECIALTY GROUP 207Q00000X
Rural Health Clinic/Center 261QR1300X Primary

Addresses

Primary practice location

965 Highway 431
Roanoke, AL 36274-7329

Mailing address

100 Greenway Blvd FL 2
Carrollton, GA 30117-4338
Phone (770) 838-8710

Medicare participation

Medicare enrollment files
Medicare fee-for-service enrollment
Enrolled in AL2 enrollments

Enrollment records 2

Enrollment IDStateProvider typePAC IDDetails
O20190425001408 AL Part B Supplier - Clinic/Group Practice 1153663091 Receives reassigned benefits from 5 practitioners
Practice locations: Auburn, AL; Roanoke, AL; Valley, AL; Wedowee, AL
O20191118001973 AL Part A Provider - Rural Health Clinic 1153663091 Practice locations: Roanoke, AL

NPI to CCN mapping 1

The Medicare certification numbers (CCNs) connected to NPI 1255899092. Details of each certification follow.

Rural health clinic certification: CCN 013484

Legal name
TANNER PRIMARY CARE OF ROANOKE INC
Certification status
Active
Provider type (POS)
Rural health clinic
Participating since
Jun 15, 2020
Last certification
Jun 15, 2020
Ownership / control type
2B
Organization structure
CorporationProprietary
Incorporated
Feb 18, 2019 in GA
Enrollment address
965 Highway 431
Roanoke, AL 36274-7329
Related CCNs
011306

Facilities connected through Provider of Services related, parent or unit certification numbers.

Laboratory certificates & supplier records

Derived by NPIMap

These CMS records do not include an NPI. They are shown because their name and street address match this provider’s.

CLIA laboratory certificates

CLIA numberLaboratoryCertificateExpires
01D0918083Tanner Primary Care of Roanoke965 Highway 431, Roanoke, AL 36274Certificate of waiverJan 23, 2028

National Provider Directory

National Provider Directory

Member of 1

Organizations this organization is a member of, according to the National Provider Directory.

Locations

1030 Main St S
Ste 201
Wedowee, AL 36278
Phone (256) 357-2188

100 Greenway Blvd
Fl 2
Carrollton, GA 30117
Phone (770) 838-8710

Ownership & related parties

All disclosed owners & managing parties 2

As disclosed on the Medicare enrollment (CMS All Owners files). Individuals include officers, directors and managing employees, who may not hold ownership.

NameRoleSinceShare
Carol Crews Individual Corporate OfficerChief Financial Officer Jun 18, 2012
W-2 Managing EmployeeChief Financial Officer Jun 18, 2012
Tanner Medical Center Alabama Inc Organization, Wedowee, AL Corporation 5% Or Greater Direct Ownership Interest Feb 18, 2019 100%

Owners & managing parties with NPI records 3

Owners and managing parties disclosed on this facility’s Medicare enrollment that are themselves Medicare-enrolled.

Facilities with the same owner 2

Facilities that share an organizational owner with 5% or greater ownership or operational control.

Practitioners & affiliated clinicians

Practitioners 5

Individual providers connected to this organization through Medicare benefit reassignment, Care Compare group membership or National Provider Directory roles, and the practitioner matching its NPPES authorized official.

NPI Registry JSON

The complete NPPES record for this NPI in the NPI Registry API format.

{
    "created_epoch": "1552348800000",
    "enumeration_type": "NPI-2",
    "last_updated_epoch": "1709164800000",
    "number": "1255899092",
    "addresses": [
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "MAILING",
            "address_type": "DOM",
            "address_1": "100 GREENWAY BLVD FL 2",
            "city": "CARROLLTON",
            "state": "GA",
            "postal_code": "301174338",
            "telephone_number": "770-838-8710",
            "fax_number": "770-812-5735"
        },
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "LOCATION",
            "address_type": "DOM",
            "address_1": "965 HIGHWAY 431",
            "city": "ROANOKE",
            "state": "AL",
            "postal_code": "362747329",
            "telephone_number": "334-863-2141",
            "fax_number": "334-863-8733"
        }
    ],
    "practiceLocations": [],
    "basic": {
        "organization_name": "TANNER PRIMARY CARE OF ROANOKE INC",
        "organizational_subpart": "NO",
        "enumeration_date": "2019-03-12",
        "last_updated": "2024-02-29",
        "certification_date": "2024-02-29",
        "status": "A",
        "authorized_official_last_name": "HOFFMAN",
        "authorized_official_first_name": "CLINT",
        "authorized_official_title_or_position": "SR VP",
        "authorized_official_telephone_number": "770-838-8302"
    },
    "taxonomies": [
        {
            "code": "207Q00000X",
            "taxonomy_group": "193400000X SINGLE SPECIALTY  GROUP",
            "desc": "Family Medicine",
            "state": null,
            "license": null,
            "primary": false
        },
        {
            "code": "261QR1300X",
            "taxonomy_group": "",
            "desc": "Clinic/Center, Rural Health",
            "state": null,
            "license": null,
            "primary": true
        }
    ],
    "identifiers": [],
    "endpoints": [],
    "other_names": []
}

Other providers in Roanoke, AL

Sources for this page

Verify at the official NPI Registry.