Healthcare Provider Details

I. General information

NPI: 1467915587
Provider Name (Legal Business Name): SAMUEL ALEXANDER KOCIOLA
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 04/08/2019
Last Update Date: 08/09/2024
Certification Date: 08/09/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

500 MEDICAL ARTS BLDG STE 540
KITTANNING PA
16201-7137
US

IV. Provider business mailing address

5300 N MEADOWS DR
GROVE CITY OH
43123-2546
US

V. Phone/Fax

Practice location:
  • Phone: 724-543-4942
  • Fax:
Mailing address:
  • Phone: 614-663-4550
  • Fax: 614-663-4555

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code208600000X
TaxonomySurgery Physician
License NumberOS023836
License Number StatePA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: