Provider Demographics
NPI:1871599605
Name:TACK, KEVIN L (MD)
Entity type:Individual
Prefix:
First Name:KEVIN
Middle Name:L
Last Name:TACK
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1615 NORTHERN BLVD
Mailing Address - Street 2:
Mailing Address - City:MANHASSET
Mailing Address - State:NY
Mailing Address - Zip Code:11030-3033
Mailing Address - Country:US
Mailing Address - Phone:516-627-3717
Mailing Address - Fax:516-869-8625
Practice Address - Street 1:1615 NORTHERN BLVD
Practice Address - Street 2:
Practice Address - City:MANHASSET
Practice Address - State:NY
Practice Address - Zip Code:11030-3033
Practice Address - Country:US
Practice Address - Phone:516-627-3717
Practice Address - Fax:516-869-8625
Is Sole Proprietor?:No
Enumeration Date:2005-06-27
Last Update Date:2009-12-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY180244207RG0100X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RG0100XAllopathic & Osteopathic PhysiciansInternal MedicineGastroenterology
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY47H441Medicare PIN
NYF51762Medicare UPIN