Provider Demographics
NPI:1093133795
Name:KOTCH, SHANNON RUTH (MD)
Entity Type:Individual
Prefix:
First Name:SHANNON
Middle Name:RUTH
Last Name:KOTCH
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:549 OVERLOOK DR
Mailing Address - Street 2:
Mailing Address - City:HOLLIDAYSBURG
Mailing Address - State:PA
Mailing Address - Zip Code:16648-3909
Mailing Address - Country:US
Mailing Address - Phone:570-332-2945
Mailing Address - Fax:
Practice Address - Street 1:620 HOWARD AVE
Practice Address - Street 2:
Practice Address - City:ALTOONA
Practice Address - State:PA
Practice Address - Zip Code:16601-4804
Practice Address - Country:US
Practice Address - Phone:570-332-2945
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2014-03-31
Last Update Date:2024-01-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PAMD4828302086S0102X, 2086S0127X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2086S0127XAllopathic & Osteopathic PhysiciansSurgeryTrauma Surgery
No2086S0102XAllopathic & Osteopathic PhysiciansSurgerySurgical Critical Care