Provider Demographics
NPI:1689743445
Name:TACKEY, FREDERICK S (MD)
Entity Type:Individual
Prefix:
First Name:FREDERICK
Middle Name:S
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:PO BOX 550
Mailing Address - Street 2:
Mailing Address - City:BOYNTON BEACH
Mailing Address - State:FL
Mailing Address - Zip Code:33425-0550
Mailing Address - Country:US
Mailing Address - Phone:561-374-8919
Mailing Address - Fax:561-374-8911
Practice Address - Street 1:2300 SOUTH CONGRESS AVENUE #101
Practice Address - Street 2:
Practice Address - City:BOYNTON BEACH
Practice Address - State:FL
Practice Address - Zip Code:33426
Practice Address - Country:US
Practice Address - Phone:561-374-8919
Practice Address - Fax:561-374-8911
Is Sole Proprietor?:No
Enumeration Date:2006-11-07
Last Update Date:2010-09-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FL0068055207R00000X, 207RC0200X, 207RP1001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RP1001XAllopathic & Osteopathic PhysiciansInternal MedicinePulmonary Disease
No207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
No207RC0200XAllopathic & Osteopathic PhysiciansInternal MedicineCritical Care Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL377890800Medicaid
F71810Medicare UPIN
FL377890800Medicaid