MEDICARE: MR. MICHAEL A RACKOVER PA-C

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	363A00000X	Physician Assistant	MA000744L	PA

General Provider Information

NPI Number	:	1225387012
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MR. MICHAEL A RACKOVER PA-C

Provider Business Mailing Address
First Line	:	557 FRANKLIN WAY
Second Line	:
City	:	WEST CHESTER
State	:	PA
Zip	:	19380-5711
Country	:	US
Telephone Number	:	484-266-0473
Fax Number	:

Provider Business Practice Location Address
First Line	:	4201 HENRY AVE
Second Line	:
City	:	PHILADELPHIA
State	:	PA
Zip	:	19144-5409
Country	:	US
Telephone Number	:	215-951-2676
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	09/07/2012
Last Update Date	:	09/07/2012

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