Lori Anne Tackman, MD

Primary specialty

Pediatrics PhysicianTaxonomy code 208000000X

License

2000-00146 Issued in NC

Practice address

20 Medical Campus Dr NW Ste 205
Supply, NC 28462

Phone

(910) 721-4400

Fax

(910) 721-4409

NPI assigned

Jun 30, 2005

Last updated

Oct 26, 2020By the provider in NPPES

Sex

Female

Sole proprietor

No

Registry information is reported by the provider to CMS and is not verified. About this source

Specialties & licenses 1

Addresses

Other identifiers 2

Electronic endpoints 1

Medicare fee-for-service enrollment

Enrolled in NC

Eligible to order & refer

• Part B services: Yes
• Medical equipment: Yes
• Home health: Yes
• Power mobility devices: Yes
• Hospice: Yes

Green means eligible to order or refer.

Enrollment records 1

Medicare enrollment (NPD)

Enrolled

Credentials

Doctor of Medicine

State licenses

Practice roles

Locations

Interoperability endpoints

• Direct secure messaging: ltackman736377@direct.novanthealth.org

Organizations this provider is connected to: Medicare benefit reassignments (the organization bills Medicare for this provider’s services), Care Compare group memberships, National Provider Directory roles and organizations whose NPPES authorized official is this provider.

• Novant Health Medical Group, LLC

  dba Novant Health Pediatric Neurology & Sleep

  • Neurology with Special Qualifications in Child Neurology Physician
  • Charlotte, NC
  • NPI 1366409492
  Medicare reassignment NPD
• Novant Health Medical Group, LLC

  dba Novant Health Elizabeth OB/GYN

  • Obstetrics & Gynecology Physician
  • Matthews, NC
  • NPI 1386506137
  NPD
• Novant Health Medical Group, LLC

  dba Novant Health Urogynecology

  • Obstetrics & Gynecology Physician
  • Charlotte, NC
  • NPI 1447414925
  NPD
• Novant Health Medical Group, LLC

  dba Novant Health Northlake Dermatology

  • Dermatopathology Physician
  • Huntersville, NC
  • NPI 1396751640
  NPD (past)
• Raleigh Durham Medical Group PA

  • Family Medicine Physician
  • Cary, NC
  • NPI 1295784874

  Pediatrics

  NPD (past)

The complete NPPES record for this NPI in the NPI Registry API format.

{
    "created_epoch": "1120089600000",
    "enumeration_type": "NPI-1",
    "last_updated_epoch": "1603670400000",
    "number": "1497752968",
    "addresses": [
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "MAILING",
            "address_type": "DOM",
            "address_1": "PO BOX 60447",
            "city": "CHARLOTTE",
            "state": "NC",
            "postal_code": "282600447"
        },
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "LOCATION",
            "address_type": "DOM",
            "address_1": "20 MEDICAL CAMPUS DR NW STE 205",
            "city": "SUPPLY",
            "state": "NC",
            "postal_code": "28462",
            "telephone_number": "910-721-4400",
            "fax_number": "910-721-4409"
        }
    ],
    "practiceLocations": [
        {
            "address_1": "97 Cornerstone Dr",
            "address_purpose": "LOCATION",
            "city": "Cary",
            "state": "NC",
            "postal_code": "275198403",
            "country_code": "US",
            "telephone_number": "919-460-0993",
            "fax_number": "919-481-3952",
            "country_name": "United States",
            "address_type": "DOM"
        },
        {
            "address_1": "97 Cornerstone Dr",
            "address_purpose": "LOCATION",
            "city": "Cary",
            "state": "NC",
            "postal_code": "275198403",
            "country_code": "US",
            "telephone_number": "919-460-0993",
            "fax_number": "919-481-3952",
            "country_name": "United States",
            "address_type": "DOM"
        }
    ],
    "basic": {
        "last_name": "TACKMAN",
        "first_name": "LORI",
        "middle_name": "ANNE",
        "credential": "MD",
        "sole_proprietor": "NO",
        "sex": "F",
        "enumeration_date": "2005-06-30",
        "last_updated": "2020-10-26",
        "certification_date": "2020-09-06",
        "status": "A"
    },
    "taxonomies": [
        {
            "code": "208000000X",
            "taxonomy_group": "",
            "desc": "Pediatrics",
            "state": "NC",
            "license": "2000-00146",
            "primary": true
        }
    ],
    "identifiers": [
        {
            "code": "01",
            "desc": "Other (non-Medicare)",
            "issuer": "BCBS",
            "identifier": "126WX",
            "state": "NC"
        },
        {
            "code": "05",
            "desc": "MEDICAID",
            "issuer": null,
            "identifier": "89126WX",
            "state": "NC"
        }
    ],
    "endpoints": [
        {
            "endpointType": "DIRECT",
            "endpointTypeDescription": "Direct Messaging Address",
            "endpoint": "ltackman736377@direct.novanthealth.org",
            "affiliation": "N",
            "address_1": "97 Cornerstone Dr",
            "city": "Cary",
            "state": "NC",
            "country_code": "US",
            "postal_code": "275198403",
            "country_name": "United States",
            "address_type": "DOM"
        }
    ],
    "other_names": []
}

• Lindsey Stack
• Samantha Sudano, MSN, RN, PMHNP-BC
• Anna Elizabeth Emerson Susol, LCSWA
• Lindian J Swaim Jr., MD
• Amanda Evelyn Swiss, PA-C
• Tender Care Company, LLC
• Thomas Speech Therapy Services PLLC
• Jennifer Renee Thomas, FNP-C
• Scott Thomas, PT
• Christopher James Toussaint, MD

• Pediatrics Physician in Supply, NC
• Providers in Supply, NC by specialty
• Pediatrics Physician in North Carolina

• NPPES NPI Registry (CMS): identity, addresses, specialties, licenses, identifiers and endpoints. Last updated by the provider on Oct 26, 2020; self-reported and not verified by CMS. Specialty names from the NUCC taxonomy.
• Medicare enrollment (CMS PECOS): enrollments, PAC IDs and benefit reassignments; Order and Referring.
• National Provider Directory (CMS): practice roles, locations, licenses, networks and endpoints.

Verify at the official NPI Registry.