1487876512 NPI number — TODD J KOTYK P.T.

Table of content: TODD J KOTYK P.T. (NPI 1487876512)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1487876512 NPI number — TODD J KOTYK P.T.

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
KOTYK
Provider First Name:
TODD
Provider Middle Name:
J
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
P.T.
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:
1487876512
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
07/08/2007
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
153 E PIKE ST
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
CANONSBURG
Provider Business Mailing Address State Name:
PA
Provider Business Mailing Address Postal Code:
15317-1765
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
724-745-5646
Provider Business Mailing Address Fax Number:
724-745-6062

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
153 EAST PIKE ST.
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
CANONSBURG
Provider Business Practice Location Address State Name:
PA
Provider Business Practice Location Address Postal Code:
15317-1765
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
724-745-5646
Provider Business Practice Location Address Fax Number:
724-745-6062
Provider Enumeration Date:
05/02/2007

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:  PT-009765-L , registered in the state of PA ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .
  • Taxonomy code: 225100000X , with the licence number: 2484 , registered in the state of WV ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .

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

  • Identifier: KO425781 . This is a "HIGHMARK BLUE SHIELD" identifier , issued by the state of ( PA ) . This identifiers is of the category "OTHER".
  • Identifier: 5139764 . This is a "AETNA PIN PPO PRODUCTS" identifier . This identifiers is of the category "OTHER".
  • Identifier: 11513356 . This is a "CAQH PROVIDER ID" identifier . This identifiers is of the category "OTHER".
  • Identifier: 1279105 . This is a "AETNA HMO PROVIDER NUMBER" identifier . This identifiers is of the category "OTHER".




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