Healthcare Provider Details

I. General information

NPI: 1114102316
Provider Name (Legal Business Name): MICHAEL COUCH JR DPM
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 01/07/2008
Last Update Date: 01/07/2008
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4011 ARROWHEAD LN
LIVERPOOL NY
13090-2821
US

IV. Provider business mailing address

PO BOX 340
NEW HARTFORD NY
13413-0340
US

V. Phone/Fax

Practice location:
  • Phone: 315-409-4165
  • Fax: 315-409-4165
Mailing address:
  • Phone: 315-732-9368
  • Fax: 315-732-9403

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code213E00000X
TaxonomyPodiatrist
License NumberN005821
License Number StateNY

VIII. Authorized Official

Name: DR. MICHAEL A COUCH JR.
Title or Position: OWNER & OPERATOR
Credential: MD
Phone: 315-409-4165