Provider Demographics
NPI:1881910420
Name:TACKETT, SEAN (MD)
Entity type:Individual
Prefix:
First Name:SEAN
Middle Name:
Last Name:TACKETT
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 1:824 S BOND ST
Mailing Address - Street 2:APT B
Mailing Address - City:BALTIMORE
Mailing Address - State:MD
Mailing Address - Zip Code:21231-3306
Mailing Address - Country:US
Mailing Address - Phone:412-370-8610
Mailing Address - Fax:
Practice Address - Street 1:4940 EASTERN AVE
Practice Address - Street 2:B-1 ROOM 114D
Practice Address - City:BALTIMORE
Practice Address - State:MD
Practice Address - Zip Code:21224-2735
Practice Address - Country:US
Practice Address - Phone:410-550-3350
Practice Address - Fax:410-550-0491
Is Sole Proprietor?:No
Enumeration Date:2010-04-07
Last Update Date:2017-08-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MDD75353207R00000X, 208M00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208M00000XAllopathic & Osteopathic PhysiciansHospitalist
No207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
MD067065100Medicaid
MD067065100Medicaid