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General NPI Number Information
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NPI Number | 1669488110
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Entity Type | Individual
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Provider Name | EDWARD O TACKEY MD
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Gender | Male
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Dates
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Enumeration Date | 08/01/2006
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Last Update Date | 08/26/2020
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Provider Practice Location Address
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Address Line | 1930 BRAEBURN CIR
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City | SALEM
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State | VA
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Zip | 24153-7388
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Country | US
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Telephone | 540-772-3707
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Fax | 540-772-3739
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Provider Business Mailing Address
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Address Line | 260 BEISER BLVD STE 201
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City | DOVER
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State | DE
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Zip | 19904-5773
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Country | US
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Telephone | 302-678-7438
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Fax | 866-984-3197
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Authorized Official
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Title or Position |
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Name |
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Credential |
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Telephone |
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 174400000X
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Taxonomy Name | Specialist
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License Number | MD24622
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License Number State | OR
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Taxonomy #2
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Taxonomy Code | 207RR0500X
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Taxonomy Name | Rheumatology Physician
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License Number | 0101243144
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License Number State | VA
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Taxonomy #3
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Taxonomy Code | 207RR0500X
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Taxonomy Name | Rheumatology Physician
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License Number | C1-0023857
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License Number State | DE
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