MEDICARE: MRS. BETHANY JANE KOEFERL PT

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	2251P0200X	Pediatric Physical Therapist	012266-1	NY

General Provider Information

NPI Number	:	1942455027
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MRS. BETHANY JANE KOEFERL PT

Provider Business Mailing Address
First Line	:	2 KEYSTONE COMMONS
Second Line	:
City	:	BALLSTON LAKE
State	:	NY
Zip	:	12019-9300
Country	:	US
Telephone Number	:	518-877-0389
Fax Number	:

Provider Business Practice Location Address
First Line	:	2 KEYSTONE COMMONS
Second Line	:
City	:	BALLSTON LAKE
State	:	NY
Zip	:	12019-9300
Country	:	US
Telephone Number	:	518-877-0389
Fax Number	:

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

Provider Enumeration Date	:	11/17/2008
Last Update Date	:	11/17/2008

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