1093799496 NPI number — MICHAEL JOHN KOURY PT

Table of content: MICHAEL JOHN KOURY PT (NPI 1093799496)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1093799496 NPI number — MICHAEL JOHN KOURY PT

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
KOURY
Provider First Name:
MICHAEL
Provider Middle Name:
JOHN
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
PT
Provider Gender Code:
M

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1093799496
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
04/21/2015
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
20211 PATIO DR
Provider Second Line Business Mailing Address:
#205
Provider Business Mailing Address City Name:
CASTRO VALLEY
Provider Business Mailing Address State Name:
CA
Provider Business Mailing Address Postal Code:
94546-4338
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
510-537-3991
Provider Business Mailing Address Fax Number:
510-537-7997

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
20211 PATIO DRIVE
Provider Second Line Business Practice Location Address:
STE 205
Provider Business Practice Location Address City Name:
CASTRO VALLEY
Provider Business Practice Location Address State Name:
CA
Provider Business Practice Location Address Postal Code:
94546
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
510-537-3991
Provider Business Practice Location Address Fax Number:
510-537-7997
Provider Enumeration Date:
11/30/2005

Additional Information

Authorized Official

Authorized Official Last Name:
Authorized Official First Name:
Authorized Official Middle Name:
Authorized Official Title or Position:
Authorized Official Telephone Number:

Provider Taxonomy Codes

  • Taxonomy code: 225100000X , with the licence number:  PT12179 , registered in the state of CA ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)

  • Identifier: ZZZ16603Z . This is a "MEDICARE GROUP PTAN" identifier , issued by the state of ( CA ) . This identifiers is of the category "OTHER".




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