Healthcare Provider Details

I. General information

NPI: 1962485045
Provider Name (Legal Business Name): MICHAEL CACKOVIC MD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 11/22/2005
Last Update Date: 07/21/2022
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1800 ZOLLINGER RD FL 4
COLUMBUS OH
43221-2800
US

IV. Provider business mailing address

395 W 12TH AVE 5TH FLOOR
COLUMBUS OH
43210-1267
US

V. Phone/Fax

Practice location:
  • Phone: 614-293-2222
  • Fax: 614-293-2200
Mailing address:
  • Phone: 614-293-9269
  • Fax: 614-293-5877

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code207V00000X
TaxonomyObstetrics & Gynecology Physician
License Number043635
License Number StateCT
# 2
Primary TaxonomyY
Taxonomy Code207VM0101X
TaxonomyMaternal & Fetal Medicine Physician
License Number35.099633
License Number StateOH

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: