MEDICARE: DR. DANIEL E TACKABURY MD

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	207Q00000X	Family Medicine Physician	4301070116	MI

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	253174	OTHER	MA	MCLAREN HEALTH PLAN
2	C7436	OTHER	MA	MCARE
3	253174	OTHER	MA	HEALTH ADVANTAGE NETWORK
4	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program
5	0988276	OTHER	MA	HEALTH PLUS
6	6872693001	OTHER	MI	CIGNA
7	7936230	OTHER	MI	AETNA
8	H21189	OTHER	MI	HEALTH ALLIANCE PLAN
9	H21189	OTHER	MI	HEALTH NET FEDERAL SERV

General Provider Information

NPI Number	:	1104807973
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	DR. DANIEL E TACKABURY MD

Provider Business Mailing Address
First Line	:	401 S BALLENGER HWY
Second Line	:
City	:	FLINT
State	:	MI
Zip	:	48532-3638
Country	:	US
Telephone Number	:	810-342-1000
Fax Number	:	810-342-1590

Provider Business Practice Location Address
First Line	:	3789 HURON ST
Second Line	:
City	:	NORTH BRANCH
State	:	MI
Zip	:	48461-8117
Country	:	US
Telephone Number	:	810-688-3093
Fax Number	:	810-688-3964

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	11/09/2005
Last Update Date	:	07/08/2007

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