Provider Demographics
NPI:1407008915
Name:MA KOYLE INC
Entity Type:Organization
Organization Name:MA KOYLE INC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CEO/PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:MARTIN
Authorized Official - Middle Name:ALLEN
Authorized Official - Last Name:KOYLE
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:818-915-1199
Mailing Address - Street 1:4924 BALBOA BLVD
Mailing Address - Street 2:SUITE 138
Mailing Address - City:ENCINO
Mailing Address - State:CA
Mailing Address - Zip Code:91316-3402
Mailing Address - Country:US
Mailing Address - Phone:818-915-1199
Mailing Address - Fax:
Practice Address - Street 1:1925 BLAKE ST
Practice Address - Street 2:SUITE 101
Practice Address - City:DENVER
Practice Address - State:CO
Practice Address - Zip Code:80202-1289
Practice Address - Country:US
Practice Address - Phone:818-915-1199
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-10-15
Last Update Date:2008-10-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CO29391208800000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes208800000XAllopathic & Osteopathic PhysiciansUrologyGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
COA26568Medicare UPIN