Provider Demographics
NPI:1265494876
Name:KOSTKA, KEVIN (PT)
Entity Type:Individual
Prefix:
First Name:KEVIN
Middle Name:
Last Name:KOSTKA
Suffix:
Gender:M
Credentials:PT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1790 HAMILL RD
Mailing Address - Street 2:
Mailing Address - City:HIXSON
Mailing Address - State:TN
Mailing Address - Zip Code:37343-4905
Mailing Address - Country:US
Mailing Address - Phone:423-842-9322
Mailing Address - Fax:186-659-1061
Practice Address - Street 1:1790 HAMILL RD
Practice Address - Street 2:
Practice Address - City:HIXSON
Practice Address - State:TN
Practice Address - Zip Code:37343-4905
Practice Address - Country:US
Practice Address - Phone:423-842-9322
Practice Address - Fax:866-591-0619
Is Sole Proprietor?:Yes
Enumeration Date:2006-04-06
Last Update Date:2015-01-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TN6817225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
TN4227742OtherBCBS TENN
TN3645730Medicaid
TN11822955OtherCAQH
TN4227742OtherBCBS TENN