Healthcare Provider Details

I. General information

NPI: 1760554364
Provider Name (Legal Business Name): MICHAEL JOHN KACKA JR. M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 11/15/2006
Last Update Date: 09/24/2016
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3209 COLONIAL DR PALMETTO HEALTH PREVENTIVE MEDICINE RESIDENCY
COLUMBIA SC
29203-6930
US

IV. Provider business mailing address

3209 COLONIAL DR PALMETTO HEALTH PREVENTIVE MEDICINE RESIDENCY
COLUMBIA SC
29203-6930
US

V. Phone/Fax

Practice location:
  • Phone: 803-434-6113
  • Fax: 803-434-7231
Mailing address:
  • Phone: 803-434-6113
  • Fax: 803-434-7231

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code2083P0901X
TaxonomyPublic Health & General Preventive Medicine Physician
License NumberMD38381
License Number StateSC

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: