Healthcare Provider Details

I. General information

NPI: 1336448125
Provider Name (Legal Business Name): MICHAEL ERNEST THACKER DPM
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 03/20/2011
Last Update Date: 09/20/2022
Certification Date: 09/20/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

425 SUMMIT TERRACE CT BLDG 7A
COLUMBIA SC
29229-7055
US

IV. Provider business mailing address

425 SUMMIT TERRACE CT BLDG 7A
COLUMBIA SC
29229-7055
US

V. Phone/Fax

Practice location:
  • Phone: 803-788-6400
  • Fax: 803-788-6544
Mailing address:
  • Phone: 803-788-6400
  • Fax: 803-788-6544

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code213E00000X
TaxonomyPodiatrist
License Number627
License Number StateSC
# 2
Primary TaxonomyN
Taxonomy Code213ES0131X
TaxonomyFoot Surgery Podiatrist
License Number627
License Number StateSC
# 3
Primary TaxonomyY
Taxonomy Code213ES0103X
TaxonomyFoot & Ankle Surgery Podiatrist
License Number627
License Number StateSC

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: