Basic Information
| Provider Information | |||||||||
| NPI: | 1811982366 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | TACKTILL | ||||||||
| FirstName: | NORMAN | ||||||||
| MiddleName: | |||||||||
| NamePrefix: | DR. | ||||||||
| NameSuffix: | |||||||||
| Credential: | MD | ||||||||
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| Mailing Information | |||||||||
| Address1: | 6355 WALKER LN | ||||||||
| Address2: | SUITE 408 | ||||||||
| City: | ALEXANDRIA | ||||||||
| State: | VA | ||||||||
| PostalCode: | 223103245 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7037195901 | ||||||||
| FaxNumber: | 7037199629 | ||||||||
| Practice Location | |||||||||
| Address1: | 6355 WALKER LN | ||||||||
| Address2: | SUITE 408 | ||||||||
| City: | ALEXANDRIA | ||||||||
| State: | VA | ||||||||
| PostalCode: | 223103245 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7037195901 | ||||||||
| FaxNumber: | 7037199629 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 09/12/2005 | ||||||||
| 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 | 207V00000X | 0101031690 | VA | Y | Allopathic & Osteopathic Physicians | Obstetrics & Gynecology |
ID Information
| ID | Type | State | Issuer | Description | 6294065 | 05 | VA | MEDICAID |