MEDICARE: ENRIQUE KOH MD

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	207Q00000X	Family Medicine Physician	MD052898L	PA

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program

General Provider Information

NPI Number	:	1184629552
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	ENRIQUE KOH MD

Provider Business Mailing Address
First Line	:	1086 FRANKLIN ST
Second Line	:
City	:	JOHNSTOWN
State	:	PA
Zip	:	15905-4305
Country	:	US
Telephone Number	:	814-410-8300
Fax Number	:	814-410-8331

Provider Business Practice Location Address
First Line	:	1100 W HIGH ST
Second Line	:
City	:	EBENSBURG
State	:	PA
Zip	:	15931-1706
Country	:	US
Telephone Number	:	814-472-7933
Fax Number	:	814-472-2301

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

Provider Enumeration Date	:	06/14/2005
Last Update Date	:	03/13/2014

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