Provider Demographics
NPI:1457501082
Name:DR. KERN S. KOO, GENERAL &FAMILY MEDICINE, P.C.
Entity Type:Organization
Organization Name:DR. KERN S. KOO, GENERAL &FAMILY MEDICINE, P.C.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:KERN
Authorized Official - Middle Name:SCOTT
Authorized Official - Last Name:KOO
Authorized Official - Suffix:
Authorized Official - Credentials:DO
Authorized Official - Phone:718-357-3458
Mailing Address - Street 1:5133 MARATHON PKWY
Mailing Address - Street 2:
Mailing Address - City:LITTLE NECK
Mailing Address - State:NY
Mailing Address - Zip Code:11362-1716
Mailing Address - Country:US
Mailing Address - Phone:718-357-3458
Mailing Address - Fax:718-357-3483
Practice Address - Street 1:5133 MARATHON PKWY
Practice Address - Street 2:
Practice Address - City:LITTLE NECK
Practice Address - State:NY
Practice Address - Zip Code:11362-1716
Practice Address - Country:US
Practice Address - Phone:718-357-3458
Practice Address - Fax:718-357-3483
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-09-18
Last Update Date:2008-09-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY221288261QP2300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QP2300XAmbulatory Health Care FacilitiesClinic/CenterPrimary Care
Provider Identifiers
StateIdentifier IDID TypeIssuer
NYH44807Medicare UPIN