MEDICARE: MERCED ORTHOPAEDIC MEDICAL GROUP, INC

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		CA

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program

General Provider Information

NPI Number	:	1326046012
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	MERCED ORTHOPAEDIC MEDICAL GROUP, INC

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

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	:

Authorized Official
Title or Position	:	MD
Name	:	DR. SAMUEL B TACKE
Credential	:	MD
Telephone Number	:	209-722-8161

Provider Enumeration Date	:	07/07/2005
Last Update Date	:	07/21/2022

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