MEDICARE: CHARLES C KO M.D.

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	2085R0202X	Diagnostic Radiology Physician	MD473648	PA
2	390200000X	Student in an Organized Health Care Education/Training Program

General Provider Information

NPI Number	:	1306208509
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	CHARLES C KO M.D.

Provider Business Mailing Address
First Line	:	1125 SANSOM ST APT 611
Second Line	:
City	:	PHILADELPHIA
State	:	PA
Zip	:	19107-4866
Country	:	US
Telephone Number	:
Fax Number	:

Provider Business Practice Location Address
First Line	:	6529 BLACK HORSE PIKE
Second Line	:
City	:	EGG HARBOR TOWNSHIP
State	:	NJ
Zip	:	08234-4509
Country	:	US
Telephone Number	:	856-459-3855
Fax Number	:

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

Provider Enumeration Date	:	03/25/2016
Last Update Date	:	12/12/2023

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