Provider Demographics
NPI:1699787804
Name:TACKETT, JAMES FAIRD (MD)
Entity type:Individual
Prefix:DR
First Name:JAMES
Middle Name:FAIRD
Last Name:TACKETT
Suffix:
Gender:
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:RR 1 BOX 46-25
Mailing Address - Street 2:
Mailing Address - City:RED HOUSE
Mailing Address - State:WV
Mailing Address - Zip Code:25168-9713
Mailing Address - Country:US
Mailing Address - Phone:304-586-0915
Mailing Address - Fax:
Practice Address - Street 1:221 NE GLEN OAK AVE
Practice Address - Street 2:
Practice Address - City:PEORIA
Practice Address - State:IL
Practice Address - Zip Code:61636-0001
Practice Address - Country:US
Practice Address - Phone:309-999-1091
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-08-13
Last Update Date:2025-04-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ALMD.30275207R00000X
WYTL7008207R00000X
IL036-117166207P00000X
WV7956207P00000X
FLME107562207P00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207P00000XAllopathic & Osteopathic PhysiciansEmergency Medicine
No207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL036117166Medicaid
IL36117166OtherBCBS
ILP00376164OtherRAILROAD MCARE
ILP00376164OtherRAILROAD MCARE