Provider Demographics
NPI:1932985850
Name:TACK, KENNETH JAMES (MD)
Entity Type:Individual
Prefix:
First Name:KENNETH
Middle Name:JAMES
Last Name:TACK
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 1:10366 STONEY POINT DR
Mailing Address - Street 2:
Mailing Address - City:SOUTH LYON
Mailing Address - State:MI
Mailing Address - Zip Code:48178-8053
Mailing Address - Country:US
Mailing Address - Phone:810-355-8281
Mailing Address - Fax:
Practice Address - Street 1:10366 STONEY POINT DR
Practice Address - Street 2:
Practice Address - City:SOUTH LYON
Practice Address - State:MI
Practice Address - Zip Code:48178-8053
Practice Address - Country:US
Practice Address - Phone:810-355-8281
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2023-09-06
Last Update Date:2023-09-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI4301043465207RI0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RI0200XAllopathic & Osteopathic PhysiciansInternal MedicineInfectious Disease