1194724773 NPI number — JOHN D KOETHE MD

Table of content: JOHN D KOETHE MD (NPI 1194724773)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1194724773 NPI number — JOHN D KOETHE MD

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
KOETHE
Provider First Name:
JOHN
Provider Middle Name:
D
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
MD
Provider Gender Code:
M

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1194724773
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
05/11/2010
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
230 W WASHINGTON SQ
Provider Second Line Business Mailing Address:
SUITE 100
Provider Business Mailing Address City Name:
PHILADELPHIA
Provider Business Mailing Address State Name:
PA
Provider Business Mailing Address Postal Code:
19106-3500
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
215-829-8420
Provider Business Mailing Address Fax Number:
215-829-8418

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
230 W WASHINGTON SQ
Provider Second Line Business Practice Location Address:
SUITE 100
Provider Business Practice Location Address City Name:
PHILADELPHIA
Provider Business Practice Location Address State Name:
PA
Provider Business Practice Location Address Postal Code:
19106-3500
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
215-829-8420
Provider Business Practice Location Address Fax Number:
215-829-8418
Provider Enumeration Date:
07/18/2005

Additional Information

Authorized Official

Authorized Official Last Name:
Authorized Official First Name:
Authorized Official Middle Name:
Authorized Official Title or Position:
Authorized Official Telephone Number:

Provider Taxonomy Codes

  • Taxonomy code: 207RN0300X , with the licence number:  033220E , registered in the state of PA ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)

  • Identifier: 0000113314605 , issued by the state of ( PA ) . This identifiers is of the category "MEDICAID".
  • Identifier: 0000407311 . This is a "BLUE CROSS/BLUE SHIELD" identifier . This identifiers is of the category "OTHER".




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