Provider Demographics
NPI:1225387012
Name:RACKOVER, MICHAEL A (PA-C)
Entity Type:Individual
Prefix:MR
First Name:MICHAEL
Middle Name:A
Last Name:RACKOVER
Suffix:
Gender:M
Credentials:PA-C
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:557 FRANKLIN WAY
Mailing Address - Street 2:
Mailing Address - City:WEST CHESTER
Mailing Address - State:PA
Mailing Address - Zip Code:19380-5711
Mailing Address - Country:US
Mailing Address - Phone:484-266-0473
Mailing Address - Fax:
Practice Address - Street 1:4201 HENRY AVE
Practice Address - Street 2:
Practice Address - City:PHILADELPHIA
Practice Address - State:PA
Practice Address - Zip Code:19144-5409
Practice Address - Country:US
Practice Address - Phone:215-951-2676
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2012-09-07
Last Update Date:2012-09-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PAMA000744L363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant