MEDICARE: MR. RICHARD KOOS C.R.N.A.

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	367500000X	Certified Registered Nurse Anesthetist	357479-1	NY

Medicare Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	P01259953	OTHER	NY	RAILROAD MEDICARE

General Provider Information

NPI Number	:	1427002773
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MR. RICHARD KOOS C.R.N.A.

Provider Business Mailing Address
First Line	:	3998 FAIR RIDGE DRIVE
Second Line	:	SUITE 300
City	:	FAIRFAX
State	:	VA
Zip	:	22033-2921
Country	:	US
Telephone Number	:	703-295-9360
Fax Number	:	703-766-9725

Provider Business Practice Location Address
First Line	:	254 CANAL ST
Second Line	:	RM 3005
City	:	NEW YORK
State	:	NY
Zip	:	10013-3501
Country	:	US
Telephone Number	:	212-941-8273
Fax Number	:

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

Provider Enumeration Date	:	05/20/2006
Last Update Date	:	04/03/2015

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