Provider Demographics
NPI:1669488110
Name:TACKEY, EDWARD O (MD)
Entity Type:Individual
Prefix:DR
First Name:EDWARD
Middle Name:O
Last Name:TACKEY
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:260 BEISER BLVD
Mailing Address - Street 2:STE 201
Mailing Address - City:DOVER
Mailing Address - State:DE
Mailing Address - Zip Code:19904-5773
Mailing Address - Country:US
Mailing Address - Phone:302-678-7438
Mailing Address - Fax:866-984-3197
Practice Address - Street 1:1930 BRAEBURN CIR
Practice Address - Street 2:
Practice Address - City:SALEM
Practice Address - State:VA
Practice Address - Zip Code:24153-7388
Practice Address - Country:US
Practice Address - Phone:540-772-3707
Practice Address - Fax:540-772-3739
Is Sole Proprietor?:No
Enumeration Date:2006-08-01
Last Update Date:2020-08-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ORMD24622174400000X
VA0101243144207RR0500X
DEC1-0023857207RR0500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RR0500XAllopathic & Osteopathic PhysiciansInternal MedicineRheumatology
No174400000XOther Service ProvidersSpecialist
Provider Identifiers
StateIdentifier IDID TypeIssuer
VA1669488110Medicaid
VAP00621111OtherMEDICARE RAILROAD
OR227217Medicaid
VAMC10435Medicare PIN
VAP00621111OtherMEDICARE RAILROAD
VAH94912Medicare UPIN
VA1669488110Medicaid