Provider Demographics
NPI:1245231414
Name:FACKOVEC, MICHAEL (MD)
Entity Type:Individual
Prefix:
First Name:MICHAEL
Middle Name:
Last Name:FACKOVEC
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 1:309 SMITHFIELD ST
Mailing Address - Street 2:SUITE 200
Mailing Address - City:PITTSBURGH
Mailing Address - State:PA
Mailing Address - Zip Code:15222-2229
Mailing Address - Country:US
Mailing Address - Phone:412-471-2111
Mailing Address - Fax:412-471-7282
Practice Address - Street 1:309 SMITHFIELD ST
Practice Address - Street 2:SUITE 200
Practice Address - City:PITTSBURGH
Practice Address - State:PA
Practice Address - Zip Code:15222-2229
Practice Address - Country:US
Practice Address - Phone:412-471-2111
Practice Address - Fax:412-471-7282
Is Sole Proprietor?:Yes
Enumeration Date:2005-08-10
Last Update Date:2012-05-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PAMD040369L207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
E60389Medicare UPIN
FA506225Medicare ID - Type Unspecified