Provider Demographics
NPI:1164542957
Name:KIRIT K KOTHARI MD PC
Entity Type:Organization
Organization Name:KIRIT K KOTHARI MD PC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:MD PRESIDENT KIRIT K KOTHARI MD PC
Authorized Official - Prefix:DR
Authorized Official - First Name:KIRIT
Authorized Official - Middle Name:K
Authorized Official - Last Name:KOTHARI
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:570-992-1234
Mailing Address - Street 1:PO BOX 637
Mailing Address - Street 2:
Mailing Address - City:BRODHEADSVILLE
Mailing Address - State:PA
Mailing Address - Zip Code:18322
Mailing Address - Country:US
Mailing Address - Phone:570-992-1234
Mailing Address - Fax:570-992-8610
Practice Address - Street 1:ROUTE 115 & SWITZGABLE ROAD
Practice Address - Street 2:
Practice Address - City:BRODHEADSVILLE
Practice Address - State:PA
Practice Address - Zip Code:18322
Practice Address - Country:US
Practice Address - Phone:570-992-1234
Practice Address - Fax:570-992-8610
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-03-29
Last Update Date:2008-07-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PAMD058095L208VP0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes208VP0000XAllopathic & Osteopathic PhysiciansPain MedicinePain MedicineGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
PAA01601248Medicaid
PAA01601248Medicaid
PA123761Medicare PIN