Provider Demographics
NPI:1336448125
Name:THACKER, MICHAEL ERNEST (DPM)
Entity Type:Individual
Prefix:DR
First Name:MICHAEL
Middle Name:ERNEST
Last Name:THACKER
Suffix:
Gender:M
Credentials:DPM
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:425 SUMMIT TERRACE CT BLDG 7A
Mailing Address - Street 2:
Mailing Address - City:COLUMBIA
Mailing Address - State:SC
Mailing Address - Zip Code:29229-7055
Mailing Address - Country:US
Mailing Address - Phone:803-788-6400
Mailing Address - Fax:803-788-6544
Practice Address - Street 1:425 SUMMIT TERRACE CT BLDG 7A
Practice Address - Street 2:
Practice Address - City:COLUMBIA
Practice Address - State:SC
Practice Address - Zip Code:29229-7055
Practice Address - Country:US
Practice Address - Phone:803-788-6400
Practice Address - Fax:803-788-6544
Is Sole Proprietor?:Yes
Enumeration Date:2011-03-20
Last Update Date:2022-09-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SC627213E00000X, 213ES0131X, 213ES0103X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes213ES0103XPodiatric Medicine & Surgery Service ProvidersPodiatristFoot & Ankle Surgery
No213E00000XPodiatric Medicine & Surgery Service ProvidersPodiatrist
No213ES0131XPodiatric Medicine & Surgery Service ProvidersPodiatristFoot Surgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
SCPD6279Medicaid