Provider Demographics
NPI:1104214535
Name:KONKLE, STEVEN E
Entity Type:Individual
Prefix:
First Name:STEVEN
Middle Name:E
Last Name:KONKLE
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 189
Mailing Address - Street 2:
Mailing Address - City:MADISON
Mailing Address - State:IN
Mailing Address - Zip Code:47250-0189
Mailing Address - Country:US
Mailing Address - Phone:812-427-2693
Mailing Address - Fax:812-427-2936
Practice Address - Street 1:1190 W MAIN ST
Practice Address - Street 2:
Practice Address - City:VEVAY
Practice Address - State:IN
Practice Address - Zip Code:47043-3639
Practice Address - Country:US
Practice Address - Phone:812-427-2693
Practice Address - Fax:812-427-2936
Is Sole Proprietor?:No
Enumeration Date:2015-01-08
Last Update Date:2015-04-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
IN412840043Medicare PIN