Basic Information
Provider Information | |||||||||
NPI: | 1902804347 | ||||||||
EntityType: | 1 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: |   | ||||||||
LastName: | KOOCH | ||||||||
FirstName: | JASON | ||||||||
MiddleName: | EVERETT | ||||||||
NamePrefix: | DR. | ||||||||
NameSuffix: |   | ||||||||
Credential: | D.O. | ||||||||
OtherOrganizationName: |   | ||||||||
OtherOrganizationType: |   | ||||||||
OtherLastName: |   | ||||||||
OtherFirstName: |   | ||||||||
OtherMiddleName: |   | ||||||||
OtherNamePrefix: |   | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: |   | ||||||||
OtherLastNameType: |   | ||||||||
Mailing Information | |||||||||
Address1: | 2775 SCHOENERSVILLE RD | ||||||||
Address2: |   | ||||||||
City: | BETHLEHEM | ||||||||
State: | PA | ||||||||
PostalCode: | 180177307 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 6108618080 | ||||||||
FaxNumber: | 6108070366 | ||||||||
Practice Location | |||||||||
Address1: | 2775 SCHOENERSVILLE RD | ||||||||
Address2: |   | ||||||||
City: | BETHLEHEM | ||||||||
State: | PA | ||||||||
PostalCode: | 180177307 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 6108618080 | ||||||||
FaxNumber: | 6108070366 | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 07/11/2005 | ||||||||
LastUpdateDate: | 05/29/2008 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: | M | ||||||||
AuthorizedOfficialLastName: |   | ||||||||
AuthorizedOfficialFirstName: |   | ||||||||
AuthorizedOfficialMiddleName: |   | ||||||||
AuthorizedOfficialTitleorPosition: |   | ||||||||
AuthorizedOfficialTelephone: |   | ||||||||
IsSoleProprietor: | N | ||||||||
IsOrganizationSubpart: |   | ||||||||
ParentOrganizationLBN: |   | ||||||||
AuthorizedOfficialNamePrefix: |   | ||||||||
AuthorizedOfficialNameSuffix: |   | ||||||||
AuthorizedOfficialCredential: |   | ||||||||
NPICertificationDate: |   |
Taxonomy Information
Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 208100000X | OS013001 | PA | Y |   | Allopathic & Osteopathic Physicians | Physical Medicine & Rehabilitation |   |
ID Information
ID | Type | State | Issuer | Description | 50044478 | 01 |   | KEYSTONE HEALTH CENTRAL | OTHER | 6432850 | 01 |   | CIGNA HEALTHCARE | OTHER | 2299715000 | 01 |   | AMERIHEALTH | OTHER | P00230776 | 01 |   | RAILROAD MEDICARE | OTHER | 1622793 | 01 |   | HIGHMARK BLUE SHIELD | OTHER | 2170526 | 01 |   | MAMSI | OTHER | 2299715000 | 01 |   | KEYSTONE HEALTH EAST | OTHER | 1011608520001 | 05 | PA |   | MEDICAID | 2299715000 | 01 |   | INDEPENDENCE BLUE CROSS | OTHER | 50044478 | 01 |   | CAPITAL BLUE CROSS | OTHER | 90338 | 01 |   | GEISINGER HEALTH PLAN | OTHER | 821131 | 01 |   | FIRST PRIORITY HEALTH | OTHER | 7466584 | 01 |   | AETNA PPO | OTHER | 2458473 | 01 |   | UNITED HEALTHCARE | OTHER | 397414 | 01 |   | HEALTH AMERICA/HEALTH ASS | OTHER | P3356842 | 01 |   | OXFORD HEALTH PLANS | OTHER |