Healthcare Provider Details

I. General information

NPI: 1467435115
Provider Name (Legal Business Name): T. ERIC SCHACKOW M.D., PH.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 11/28/2005
Last Update Date: 01/24/2024
Certification Date: 01/24/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

120 HOBART ST
UTICA NY
13501-4308
US

IV. Provider business mailing address

120 HOBART ST
UTICA NY
13501-4308
US

V. Phone/Fax

Practice location:
  • Phone: 315-798-1149
  • Fax: 315-801-3565
Mailing address:
  • Phone: 315-798-1149
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License Number036099827
License Number StateIL
# 2
Primary TaxonomyN
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License NumberMD456820
License Number StatePA
# 3
Primary TaxonomyY
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License Number209615
License Number StateNY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: