Healthcare Provider Details

I. General information

NPI: 1326046012
Provider Name (Legal Business Name): MERCED ORTHOPAEDIC MEDICAL GROUP, INC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 07/07/2005
Last Update Date: 07/21/2022
Certification Date: 03/27/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

123 W NORTH BEAR CREEK DR
MERCED CA
95348-3420
US

IV. Provider business mailing address

123 W NORTH BEAR CREEK DRIVE
MERCED CA
95348
US

V. Phone/Fax

Practice location:
  • Phone: 209-722-8161
  • Fax:
Mailing address:
  • Phone: 209-722-8161
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207X00000X
TaxonomyOrthopaedic Surgery Physician
License Number
License Number StateCA

VIII. Authorized Official

Name: DR. SAMUEL B TACKE
Title or Position: MD
Credential: MD
Phone: 209-722-8161