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
State | License ID | Taxonomies |
---|---|---|
IL | 036099827 | 207Q00000X |
PA | MD456820 | 207Q00000X |
NY | 209615 | 207Q00000X |
Provider Taxonomies
Primary? | Code | Type | Classification | Specialization |
---|---|---|---|---|
Yes | 207Q00000X | Allopathic & Osteopathic Physicians | Family Medicine |
Provider Identifiers
State | Identifier ID | ID Type | Issuer |
---|---|---|---|
NY | 01805614 | Medicaid | |
IL | 036099827 | Medicaid | |
PA | 1031143200001 | Medicaid | |
NY | 01805614 | Medicaid | |
IL | L73697 | Medicare PIN | |
PA | 488175N86 | Medicare PIN | |
NY | G66238 | Medicare UPIN |