Healthcare Provider Details

I. General information

NPI: 1336567643
Provider Name (Legal Business Name): SHILOH TACKETT
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 04/03/2014
Last Update Date: 04/07/2026
Certification Date: 04/07/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

5087 N ROYAL DR
TRAVERSE CITY MI
49684-6987
US

IV. Provider business mailing address

550 MUNSON AVE
TRAVERSE CITY MI
49686-3580
US

V. Phone/Fax

Practice location:
  • Phone: 231-935-0440
  • Fax: 231-935-0445
Mailing address:
  • Phone: 231-935-6600
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207RP1001X
TaxonomyPulmonary Disease Physician
License Number4301502100
License Number StateMI
# 2
Primary TaxonomyN
Taxonomy Code207RC0200X
TaxonomyCritical Care Medicine (Internal Medicine) Physician
License Number4301502100
License Number StateMI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: