Provider Demographics
NPI:1336124288
Name:TACKE, BILL J (MD)
Entity Type:Individual
Prefix:MR
First Name:BILL
Middle Name:J
Last Name:TACKE
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
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Mailing Address - Street 1:500 15TH AVE S
Mailing Address - Street 2:SUITE ONE
Mailing Address - City:GREAT FALLS
Mailing Address - State:MT
Mailing Address - Zip Code:59405-4304
Mailing Address - Country:US
Mailing Address - Phone:406-455-2140
Mailing Address - Fax:406-455-2141
Practice Address - Street 1:500 15TH AVE S
Practice Address - Street 2:SUITE ONE
Practice Address - City:GREAT FALLS
Practice Address - State:MT
Practice Address - Zip Code:59405-4304
Practice Address - Country:US
Practice Address - Phone:406-455-2149
Practice Address - Fax:406-455-2141
Is Sole Proprietor?:No
Enumeration Date:2005-12-14
Last Update Date:2013-09-16
Deactivation Date:
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Provider Licenses
StateLicense IDTaxonomies
MT4564208100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208100000XAllopathic & Osteopathic PhysiciansPhysical Medicine & Rehabilitation
Provider Identifiers
StateIdentifier IDID TypeIssuer
MT250002667OtherRR MEDICARE
MT0013286Medicaid
MTM000001494Medicare PIN
MT0013286Medicaid