Provider Demographics
NPI:1376582015
Name:TACK, MARC (DO)
Entity Type:Individual
Prefix:
First Name:MARC
Middle Name:
Last Name:TACK
Suffix:
Gender:M
Credentials:DO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:360 WASHINGTON AVE
Mailing Address - Street 2:
Mailing Address - City:KINGSTON
Mailing Address - State:NY
Mailing Address - Zip Code:12401-3702
Mailing Address - Country:US
Mailing Address - Phone:845-338-7140
Mailing Address - Fax:845-338-7141
Practice Address - Street 1:360 WASHINGTON AVE
Practice Address - Street 2:
Practice Address - City:KINGSTON
Practice Address - State:NY
Practice Address - Zip Code:12401-3702
Practice Address - Country:US
Practice Address - Phone:845-338-7140
Practice Address - Fax:845-338-7141
Is Sole Proprietor?:No
Enumeration Date:2006-06-06
Last Update Date:2010-04-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY191978207RI0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RI0200XAllopathic & Osteopathic PhysiciansInternal MedicineInfectious Disease
Provider Identifiers
StateIdentifier IDID TypeIssuer
NYG27879Medicare UPIN
NYMT009N2110Medicare ID - Type Unspecified
NY01663074Medicare ID - Type Unspecified