Healthcare Provider Details

I. General information

NPI: 1346690252
Provider Name (Legal Business Name): JACQUELINE KOSHOREK D.O
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/21/2016
Last Update Date: 06/21/2016
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

169 ASHLEY AVE ROOM 202 MAIN HOSPITAL MSC333
CHARLESTON SC
29425-8905
US

IV. Provider business mailing address

169 ASHLEY AVE ROOM 202 MAIN HOSPITAL MSC333
CHARLESTON SC
29425-8905
US

V. Phone/Fax

Practice location:
  • Phone: 843-792-3222
  • Fax: 843-792-8626
Mailing address:
  • Phone: 843-792-3222
  • Fax: 843-792-8626

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code2084N0400X
TaxonomyNeurology Physician
License NumberLL39797
License Number StateSC

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: