Healthcare Provider Details

I. General information

NPI: 1518224872
Provider Name (Legal Business Name): MATTHEW THOMAS KOROSCIL M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 04/11/2012
Last Update Date: 07/10/2019
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4881 SUGAR MAPLE DR BLDG 830
WRIGHT PATTERSON AFB OH
45433-5529
US

IV. Provider business mailing address

4881 SUGAR MAPLE DR BLDG 830
WRIGHT PATTERSON AFB OH
45433-5529
US

V. Phone/Fax

Practice location:
  • Phone: 210-916-2153
  • Fax: 210-916-0709
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code208D00000X
TaxonomyGeneral Practice Physician
License Number0101255503
License Number StateVA
# 2
Primary TaxonomyY
Taxonomy Code207RP1001X
TaxonomyPulmonary Disease Physician
License Number35135125
License Number StateOH

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: