Provider Demographics
NPI:1417050402
Name:KONIN, JEFF G (PT, PHD, ATC)
Entity Type:Individual
Prefix:DR
First Name:JEFF
Middle Name:G
Last Name:KONIN
Suffix:
Gender:M
Credentials:PT, PHD, ATC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:25 W INDEPENDENCE WAY
Mailing Address - Street 2:
Mailing Address - City:KINGSTON
Mailing Address - State:RI
Mailing Address - Zip Code:02881-1126
Mailing Address - Country:US
Mailing Address - Phone:401-874-5627
Mailing Address - Fax:
Practice Address - Street 1:25 W INDEPENDENCE WAY
Practice Address - Street 2:UNIVERSITY OF RHODE ISLAND
Practice Address - City:KINGSTON
Practice Address - State:RI
Practice Address - Zip Code:02881-1126
Practice Address - Country:US
Practice Address - Phone:401-874-5627
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-09-06
Last Update Date:2016-12-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
RI026602251S0007X
FL228482251X0800X
2255A2300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2251S0007XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical TherapistSports
Not Answered2251X0800XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical TherapistOrthopedic
Not Answered2255A2300XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersSpecialist/TechnologistAthletic Trainer
Provider Identifiers
StateIdentifier IDID TypeIssuer
RI2251S0007Medicare UPIN