Provider Demographics
NPI: | 1164438883 |
---|---|
Name: | KOCHMAN, MICHAEL LEE (MD) |
Entity Type: | Individual |
Prefix: | |
First Name: | MICHAEL |
Middle Name: | LEE |
Last Name: | KOCHMAN |
Suffix: | |
Gender: | M |
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: | 3400 CIVIC CENTER BLVD |
Mailing Address - Street 2: | PCAM 4 SOUTH |
Mailing Address - City: | PHILADELPHIA |
Mailing Address - State: | PA |
Mailing Address - Zip Code: | 19104-5127 |
Mailing Address - Country: | US |
Mailing Address - Phone: | 215-349-8222 |
Mailing Address - Fax: | |
Practice Address - Street 1: | 3400 CIVIC CENTER BLVD |
Practice Address - Street 2: | PCAM 4 SOUTH |
Practice Address - City: | PHILADELPHIA |
Practice Address - State: | PA |
Practice Address - Zip Code: | 19104-5127 |
Practice Address - Country: | US |
Practice Address - Phone: | 215-349-8222 |
Practice Address - Fax: | |
Is Sole Proprietor?: | No |
Enumeration Date: | 2006-08-01 |
Last Update Date: | 2019-10-15 |
Deactivation Date: | |
Deactivation Code: | |
Reactivation Date: |
Provider Licenses
State | License ID | Taxonomies |
---|---|---|
PA | MD049908L | 207R00000X, 207RG0100X |
Provider Taxonomies
Primary? | Code | Type | Classification | Specialization |
---|---|---|---|---|
Yes | 207RG0100X | Allopathic & Osteopathic Physicians | Internal Medicine | Gastroenterology |
No | 207R00000X | Allopathic & Osteopathic Physicians | Internal Medicine |
Provider Identifiers
State | Identifier ID | ID Type | Issuer |
---|---|---|---|
PA | 001418914 | Medicaid | |
PA | F56000 | Medicare UPIN | |
PA | F56000 | Medicare UPIN |