=====================================================
General NPI Number Information
=====================================================
NPI Number | 1962485045
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | MICHAEL CACKOVIC MD
-----------------------------------------------------
Gender | Male
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 11/22/2005
-----------------------------------------------------
Last Update Date | 07/21/2022
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 1800 ZOLLINGER RD FL 4
-----------------------------------------------------
City | COLUMBUS
-----------------------------------------------------
State | OH
-----------------------------------------------------
Zip | 43221-2800
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 614-293-2222
-----------------------------------------------------
Fax | 614-293-2200
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 395 W 12TH AVE 5TH FLOOR
-----------------------------------------------------
City | COLUMBUS
-----------------------------------------------------
State | OH
-----------------------------------------------------
Zip | 43210-1267
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 614-293-9269
-----------------------------------------------------
Fax | 614-293-5877
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 207V00000X
-----------------------------------------------------
Taxonomy Name | Obstetrics & Gynecology Physician
-----------------------------------------------------
License Number | 043635
-----------------------------------------------------
License Number State | CT
-----------------------------------------------------
Taxonomy #2
-----------------------------------------------------
Taxonomy Code | 207VM0101X
-----------------------------------------------------
Taxonomy Name | Maternal & Fetal Medicine Physician
-----------------------------------------------------
License Number | 35.099633
-----------------------------------------------------
License Number State | OH
-----------------------------------------------------