Provider Demographics
NPI:1962607424
Name:QUACKENBUSH, MICHAEL IAN (DO)
Entity type:Individual
Prefix:DR
First Name:MICHAEL
Middle Name:IAN
Last Name:QUACKENBUSH
Suffix:
Gender:M
Credentials:DO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Credentials:
Mailing Address - Street 1:4500 HOSPITAL BLVD STE 230
Mailing Address - Street 2:
Mailing Address - City:ROSWELL
Mailing Address - State:GA
Mailing Address - Zip Code:30076-0001
Mailing Address - Country:US
Mailing Address - Phone:770-956-4560
Mailing Address - Fax:770-475-8968
Practice Address - Street 1:1285 HEMBREE RD
Practice Address - Street 2:SUITE 200A
Practice Address - City:ROSWELL
Practice Address - State:GA
Practice Address - Zip Code:30076-5720
Practice Address - Country:US
Practice Address - Phone:770-475-2710
Practice Address - Fax:770-360-0498
Is Sole Proprietor?:No
Enumeration Date:2007-06-15
Last Update Date:2021-10-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH34009678207XX0801X
GA072421207X00000X
NJ25MB08109900207XX0801X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207X00000XAllopathic & Osteopathic PhysiciansOrthopaedic Surgery
No207XX0801XAllopathic & Osteopathic PhysiciansOrthopaedic SurgeryOrthopaedic Trauma
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA003149994AMedicaid
OH2987237Medicaid
GA202I708795Medicare PIN
OH2987237Medicaid