MEDICARE: MATTHEW KOENNECKE PT, DPT

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	225200000X	Physical Therapy Assistant	TE012300	PA
2	225100000X	Physical Therapist	048948	NY

General Provider Information

NPI Number	:	1134760416
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MATTHEW KOENNECKE PT, DPT

Provider Business Mailing Address
First Line	:	419 E MAIN ST STE 110
Second Line	:
City	:	MIDDLETOWN
State	:	NY
Zip	:	10940-2552
Country	:	US
Telephone Number	:	845-344-1899
Fax Number	:

Provider Business Practice Location Address
First Line	:	419 E MAIN ST STE 110
Second Line	:
City	:	MIDDLETOWN
State	:	NY
Zip	:	10940-2552
Country	:	US
Telephone Number	:	845-344-1899
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	10/08/2019
Last Update Date	:	08/11/2022

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