Healthcare Provider Details

I. General information

NPI: 1154460665
Provider Name (Legal Business Name): PHILIP J KOCH PT
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 02/05/2007
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

99 TULIP AVE SUITE 407
FLORAL PARK NY
11001-1974
US

IV. Provider business mailing address

31 STONYWOOD DR
COMMACK NY
11725-5111
US

V. Phone/Fax

Practice location:
  • Phone: 516-358-9146
  • Fax:
Mailing address:
  • Phone: 631-543-0549
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code225100000X
TaxonomyPhysical Therapist
License Number006167
License Number StateNY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: