Provider Demographics
NPI:1992826366
Name:TRACY J TACKET DO PLLC
Entity Type:Organization
Organization Name:TRACY J TACKET DO PLLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:TRACY
Authorized Official - Middle Name:J
Authorized Official - Last Name:TACKET
Authorized Official - Suffix:
Authorized Official - Credentials:DO
Authorized Official - Phone:269-684-5002
Mailing Address - Street 1:3061 CHRISTY WAY
Mailing Address - Street 2:
Mailing Address - City:SAGINAW
Mailing Address - State:MI
Mailing Address - Zip Code:48603-2267
Mailing Address - Country:US
Mailing Address - Phone:989-791-2455
Mailing Address - Fax:
Practice Address - Street 1:24 N SAINT JOSEPH AVE
Practice Address - Street 2:SUITE G
Practice Address - City:NILES
Practice Address - State:MI
Practice Address - Zip Code:49120-2263
Practice Address - Country:US
Practice Address - Phone:269-684-5002
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-04-03
Last Update Date:2010-03-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI5101017117207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI4994944Medicaid
MI0P44810Medicare PIN
MI4994944Medicaid