Healthcare Provider Details

I. General information

NPI: 1912399189
Provider Name (Legal Business Name): BRAD KOEGEL
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 02/25/2015
Last Update Date: 11/12/2020
Certification Date: 11/12/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

30-46 35TH STREET
ASTORIA NY
11103
US

IV. Provider business mailing address

3046 35TH ST
ASTORIA NY
11103-4702
US

V. Phone/Fax

Practice location:
  • Phone: 516-425-3112
  • Fax:
Mailing address:
  • Phone: 516-425-3112
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code225100000X
TaxonomyPhysical Therapist
License Number043263-1
License Number StateNY
# 2
Primary TaxonomyN
Taxonomy Code171M00000X
TaxonomyCase Manager/Care Coordinator
License Number
License Number StateNY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: