Basic Information
| Provider Information | |||||||||
| NPI: | 1104807973 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | TACKABURY | ||||||||
| FirstName: | DANIEL | ||||||||
| MiddleName: | E | ||||||||
| NamePrefix: | DR. | ||||||||
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| Credential: | MD | ||||||||
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| Mailing Information | |||||||||
| Address1: | 401 S BALLENGER HWY | ||||||||
| Address2: | |||||||||
| City: | FLINT | ||||||||
| State: | MI | ||||||||
| PostalCode: | 485323638 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8103421000 | ||||||||
| FaxNumber: | 8103421590 | ||||||||
| Practice Location | |||||||||
| Address1: | 3789 HURON ST | ||||||||
| Address2: | |||||||||
| City: | NORTH BRANCH | ||||||||
| State: | MI | ||||||||
| PostalCode: | 484618117 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8106883093 | ||||||||
| FaxNumber: | 8106883964 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 11/09/2005 | ||||||||
| LastUpdateDate: | 07/08/2007 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | X | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207Q00000X | 4301070116 | MI | Y | Allopathic & Osteopathic Physicians | Family Medicine |
ID Information
| ID | Type | State | Issuer | Description | 253174 | 01 | MA | MCLAREN HEALTH PLAN | OTHER | C7436 | 01 | MA | MCARE | OTHER | 253174 | 01 | MA | HEALTH ADVANTAGE NETWORK | OTHER | 4226712 | 05 | MI | MEDICAID | 0988276 | 01 | MA | HEALTH PLUS | OTHER | 6872693001 | 01 | MI | CIGNA | OTHER | 7936230 | 01 | MI | AETNA | OTHER | H21189 | 01 | MI | HEALTH ALLIANCE PLAN | OTHER | H21189 | 01 | MI | HEALTH NET FEDERAL SERV | OTHER |