Provider Demographics
NPI:1508961806
Name:KOHL, JACK HARVEY (MD)
Entity Type:Individual
Prefix:
First Name:JACK
Middle Name:HARVEY
Last Name:KOHL
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1776 BROADWAY STE 1200
Mailing Address - Street 2:ADVANCED PSYCHIATRIC PERSPECTIVES
Mailing Address - City:NEW YORK
Mailing Address - State:NY
Mailing Address - Zip Code:10019-2002
Mailing Address - Country:US
Mailing Address - Phone:212-707-8662
Mailing Address - Fax:212-582-0888
Practice Address - Street 1:1776 BROADWAY STE 1200
Practice Address - Street 2:ADVANCED PSYCHIATRIC PERSPECTIVES
Practice Address - City:NEW YORK
Practice Address - State:NY
Practice Address - Zip Code:10019-2002
Practice Address - Country:US
Practice Address - Phone:212-707-8662
Practice Address - Fax:212-582-0888
Is Sole Proprietor?:No
Enumeration Date:2006-09-13
Last Update Date:2008-04-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY2402892084P0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2084P0800XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyPsychiatry
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY02822186Medicaid
NYI68486Medicare UPIN
NY02822186Medicaid