Provider Demographics
NPI:1114102316
Name:MICHAEL COUCH JR DPM
Entity Type:Organization
Organization Name:MICHAEL COUCH JR DPM
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER & OPERATOR
Authorized Official - Prefix:DR
Authorized Official - First Name:MICHAEL
Authorized Official - Middle Name:A
Authorized Official - Last Name:COUCH
Authorized Official - Suffix:JR
Authorized Official - Credentials:MD
Authorized Official - Phone:315-409-4165
Mailing Address - Street 1:PO BOX 340
Mailing Address - Street 2:
Mailing Address - City:NEW HARTFORD
Mailing Address - State:NY
Mailing Address - Zip Code:13413-0340
Mailing Address - Country:US
Mailing Address - Phone:315-732-9368
Mailing Address - Fax:315-732-9403
Practice Address - Street 1:4011 ARROWHEAD LN
Practice Address - Street 2:
Practice Address - City:LIVERPOOL
Practice Address - State:NY
Practice Address - Zip Code:13090-2821
Practice Address - Country:US
Practice Address - Phone:315-409-4165
Practice Address - Fax:315-409-4165
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-01-07
Last Update Date:2008-01-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NYN005821213E00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes213E00000XPodiatric Medicine & Surgery Service ProvidersPodiatristGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY02165644Medicaid
NY02165644Medicaid