Provider Demographics
NPI:1114082427
Name:KOSTUCH, JOSEPH MICHAEL (DC)
Entity Type:Individual
Prefix:DR
First Name:JOSEPH
Middle Name:MICHAEL
Last Name:KOSTUCH
Suffix:
Gender:M
Credentials:DC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:73 HENNIG DR
Mailing Address - Street 2:
Mailing Address - City:PITTSBURGH
Mailing Address - State:PA
Mailing Address - Zip Code:15236-1523
Mailing Address - Country:US
Mailing Address - Phone:412-650-7779
Mailing Address - Fax:
Practice Address - Street 1:306 CURRY HOLLOW RD
Practice Address - Street 2:
Practice Address - City:PITTSBURGH
Practice Address - State:PA
Practice Address - Zip Code:15236-4621
Practice Address - Country:US
Practice Address - Phone:412-650-7779
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2006-12-27
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PADC009021111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes111N00000XChiropractic ProvidersChiropractor
Provider Identifiers
StateIdentifier IDID TypeIssuer
PA1546432Medicaid
PAU96192Medicare UPIN
PAJK071841Medicare ID - Type Unspecified