Healthcare Provider Details

I. General information

NPI: 1164441275
Provider Name (Legal Business Name): DANIEL M TKACH M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/19/2006
Last Update Date: 11/24/2010
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2601 KENTUCKY AVE STE 401
PADUCAH KY
42003-3827
US

IV. Provider business mailing address

2601 KENTUCKY AVE STE 401
PADUCAH KY
42003-3827
US

V. Phone/Fax

Practice location:
  • Phone: 270-444-8200
  • Fax: 270-444-8398
Mailing address:
  • Phone: 270-444-8200
  • Fax: 270-444-8398

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code208200000X
TaxonomyPlastic Surgery Physician
License Number30632
License Number StateKY
# 2
Primary TaxonomyN
Taxonomy Code2086S0105X
TaxonomySurgery of the Hand (Surgery) Physician
License Number30632
License Number StateKY
# 3
Primary TaxonomyN
Taxonomy Code2086S0122X
TaxonomyPlastic and Reconstructive Surgery Physician
License Number30632
License Number StateKY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: