Provider Demographics
NPI:1467435115
Name:SCHACKOW, T. ERIC (MD, PHD)
Entity Type:Individual
Prefix:DR
First Name:T. ERIC
Middle Name:
Last Name:SCHACKOW
Suffix:
Gender:M
Credentials:MD, PHD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:120 HOBART ST
Mailing Address - Street 2:
Mailing Address - City:UTICA
Mailing Address - State:NY
Mailing Address - Zip Code:13501-4308
Mailing Address - Country:US
Mailing Address - Phone:315-798-1149
Mailing Address - Fax:
Practice Address - Street 1:120 HOBART ST
Practice Address - Street 2:
Practice Address - City:UTICA
Practice Address - State:NY
Practice Address - Zip Code:13501-4308
Practice Address - Country:US
Practice Address - Phone:315-798-1149
Practice Address - Fax:315-801-3565
Is Sole Proprietor?:No
Enumeration Date:2005-11-28
Last Update Date:2024-01-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL036099827207Q00000X
PAMD456820207Q00000X
NY209615207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY01805614Medicaid
IL036099827Medicaid
PA1031143200001Medicaid
NY01805614Medicaid
ILL73697Medicare PIN
PA488175N86Medicare PIN
NYG66238Medicare UPIN