Healthcare Provider Details

I. General information

NPI: 1730818311
Provider Name (Legal Business Name): MICHAEL GIACOPASI
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 06/08/2022
Last Update Date: 06/08/2022
Certification Date: 06/08/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

5901 SOUTHWEST PKWY
AUSTIN TX
78735-6220
US

IV. Provider business mailing address

1801 E PALM VALLEY BLVD APT 121
ROUND ROCK TX
78664-9470
US

V. Phone/Fax

Practice location:
  • Phone: 845-216-0606
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207PS0010X
TaxonomySports Medicine (Emergency Medicine) Physician
License NumberAT8651
License Number StateTX

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: