MEDICARE: KOTH THERAPY & FITNESS, LLC

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	225100000X	Physical Therapist	458R	MD

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	LN18KO	OTHER	MD	BCBS
2	2938436	OTHER	MD	AETNA

General Provider Information

NPI Number	:	1881722775
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	KOTH THERAPY & FITNESS, LLC

Provider Business Mailing Address
First Line	:	PO BOX 398
Second Line	:
City	:	CHARLOTTE HALL
State	:	MD
Zip	:	20622-0398
Country	:	US
Telephone Number	:	301-884-0331
Fax Number	:	301-472-4388

Provider Business Practice Location Address
First Line	:	30387 THREE NOTCH ROAD
Second Line	:
City	:	CHARLOTTE HALL
State	:	MD
Zip	:	20622-3183
Country	:	US
Telephone Number	:	301-884-0331
Fax Number	:	301-472-4388

Authorized Official
Title or Position	:	PT
Name	:	CHRISTOPHER R KOTH
Credential	:	PT
Telephone Number	:	301-884-0331

Provider Enumeration Date	:	03/01/2007
Last Update Date	:	08/01/2016

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