Provider Demographics
NPI:1336567643
Name:TACKETT, SHILOH
Entity Type:Individual
Prefix:
First Name:SHILOH
Middle Name:
Last Name:TACKETT
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:550 MUNSON AVE
Mailing Address - Street 2:
Mailing Address - City:TRAVERSE CITY
Mailing Address - State:MI
Mailing Address - Zip Code:49686-3580
Mailing Address - Country:US
Mailing Address - Phone:231-935-6600
Mailing Address - Fax:
Practice Address - Street 1:5087 N ROYAL DR
Practice Address - Street 2:
Practice Address - City:TRAVERSE CITY
Practice Address - State:MI
Practice Address - Zip Code:49684-6987
Practice Address - Country:US
Practice Address - Phone:231-935-0440
Practice Address - Fax:231-935-0445
Is Sole Proprietor?:No
Enumeration Date:2014-04-03
Last Update Date:2021-04-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
390200000X
MI4301502100207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program