Healthcare Provider Details

I. General information

NPI: 1942613369
Provider Name (Legal Business Name): MIA CHWAN KO
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/03/2014
Last Update Date: 09/26/2019
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

5401 OLD YORK RD STE 404
PHILADELPHIA PA
19141-3046
US

IV. Provider business mailing address

1101 E HECTOR ST UNIT 434
CONSHOHOCKEN PA
19428-2456
US

V. Phone/Fax

Practice location:
  • Phone: 856-342-2445
  • Fax:
Mailing address:
  • Phone: 646-709-3236
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code2084N0400X
TaxonomyNeurology Physician
License NumberOS018906
License Number StatePA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: