MEDICARE: JOHN D KOETHE MD

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	207RN0300X	Nephrology Physician	033220E	PA

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program
2	0000407311	OTHER		BLUE CROSS/BLUE SHIELD

General Provider Information

NPI Number	:	1194724773
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	JOHN D KOETHE MD

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

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

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

Provider Enumeration Date	:	07/18/2005
Last Update Date	:	05/11/2010

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Directions to “ JOHN D KOETHE MD” Practice Location

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