| Doctor Name: | DR. EDWARD O TACKEY |
| NPI Number: | 1669488110 |
| Entity Type Code: | Individual (1) |
| Gender: | M |
| Credentials: | MD |
| License Number: | MD24622 |
| Business Practice Address: | 1930 Braeburn Cir Salem, VA - 241537388 |
| Business Phone Number: | 5407723707 |
| Business Fax Number: | 5407723739 |
| Mailing Address: | Po Box 403901, ATLANTA |
| State: | GA |
| Postal Code: | 303843901 |
| Phone Number: | 8167014101 |
| Fax Number: | 8662988944 |
| NPI Enumeration Date: | 08/01/2006 |
| NPI Last Update Date: | 02/11/2013 |
| Replacement NPI: | 0 |
| NPI Deactivation Date: | |
| NPI Reactivation Date: |
Taxonomy Information: | |
| Healthcare Provider Taxonomy: | 174400000X |
| License Number: | MD24622 |
| Healthcare Provider Taxonomy: (Secondary) | N |
| State: | OR |
| Taxonomy Type: | Other Service Providers |
| Taxonomy Classification: | Specialist |
| Taxonomy Specialization: | |
| Taxonomy Definition: | An individual educated and trained in an applied knowledge discipline used in the performance of work at a level requiring knowledge and skills beyond or apart from that provided by a general education or liberal arts degree. |