MEDICARE: MR. PETER M. KOEHNEKE ATC

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	2255A2300X	Athletic Trainer	5077035	NY

General Provider Information

NPI Number	:	1407820905
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MR. PETER M. KOEHNEKE ATC

Provider Business Mailing Address
First Line	:	73 ALLENHURST RD
Second Line	:
City	:	BUFFALO
State	:	NY
Zip	:	14214-1203
Country	:	US
Telephone Number	:	716-888-2954
Fax Number	:	716-888-3216

Provider Business Practice Location Address
First Line	:	2001 MAIN ST
Second Line	:
City	:	BUFFALO
State	:	NY
Zip	:	14208-1035
Country	:	US
Telephone Number	:	716-888-2954
Fax Number	:	716-888-3216

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

Provider Enumeration Date	:	02/14/2006
Last Update Date	:	07/08/2007

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