Healthcare Provider Details

I. General information

NPI: 1699787804
Provider Name (Legal Business Name): JAMES FAIRD TACKETT MD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 08/13/2006
Last Update Date: 04/07/2025
Certification Date: 04/07/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

221 NE GLEN OAK AVE
PEORIA IL
61636-0001
US

IV. Provider business mailing address

RR 1 BOX 46-25
RED HOUSE WV
25168-9713
US

V. Phone/Fax

Practice location:
  • Phone: 309-999-1091
  • Fax:
Mailing address:
  • Phone: 304-586-0915
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code207P00000X
TaxonomyEmergency Medicine Physician
License Number036-117166
License Number StateIL
# 2
Primary TaxonomyN
Taxonomy Code207P00000X
TaxonomyEmergency Medicine Physician
License Number7956
License Number StateWV
# 3
Primary TaxonomyY
Taxonomy Code207P00000X
TaxonomyEmergency Medicine Physician
License NumberME107562
License Number StateFL
# 4
Primary TaxonomyN
Taxonomy Code207R00000X
TaxonomyInternal Medicine Physician
License NumberMD.30275
License Number StateAL
# 5
Primary TaxonomyN
Taxonomy Code207R00000X
TaxonomyInternal Medicine Physician
License NumberTL7008
License Number StateWY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: