Provider Demographics
NPI:1497752968
Name:TACKMAN, LORI ANNE (MD)
Entity Type:Individual
Prefix:
First Name:LORI
Middle Name:ANNE
Last Name:TACKMAN
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 60447
Mailing Address - Street 2:
Mailing Address - City:CHARLOTTE
Mailing Address - State:NC
Mailing Address - Zip Code:28260-0447
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:20 MEDICAL CAMPUS DR NW STE 205
Practice Address - Street 2:
Practice Address - City:SUPPLY
Practice Address - State:NC
Practice Address - Zip Code:28462
Practice Address - Country:US
Practice Address - Phone:910-721-4400
Practice Address - Fax:910-721-4409
Is Sole Proprietor?:No
Enumeration Date:2005-06-30
Last Update Date:2020-10-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC2000-00146208000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208000000XAllopathic & Osteopathic PhysiciansPediatrics
Provider Identifiers
StateIdentifier IDID TypeIssuer
NC126WXOtherBCBS
NC89126WXMedicaid
NC126WXOtherBCBS