MEDICARE: SAMUEL B TACKE M.D.

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	207X00000X	Orthopaedic Surgery Physician	G60593	CA

General Provider Information

NPI Number	:	1235236993
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	SAMUEL B TACKE M.D.

Provider Business Mailing Address
First Line	:	123 W NORTH BEAR CREEK DR
Second Line	:
City	:	MERCED
State	:	CA
Zip	:	95348-3420
Country	:	US
Telephone Number	:	209-722-8161
Fax Number	:	209-383-9211

Provider Business Practice Location Address
First Line	:	123 W NORTH BEAR CREEK DR
Second Line	:
City	:	MERCED
State	:	CA
Zip	:	95348-3420
Country	:	US
Telephone Number	:	209-722-8161
Fax Number	:	209-383-9211

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

Provider Enumeration Date	:	09/17/2006
Last Update Date	:	05/07/2008

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