Provider Demographics
NPI:1578089645
Name:KOERTH, TYLER (ATC)
Entity Type:Individual
Prefix:
First Name:TYLER
Middle Name:
Last Name:KOERTH
Suffix:
Gender:M
Credentials:ATC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4014 TERNWOOD DR APT 1A
Mailing Address - Street 2:
Mailing Address - City:KALAMAZOO
Mailing Address - State:MI
Mailing Address - Zip Code:49048-6674
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:10425 PANTHER PRIDE
Practice Address - Street 2:
Practice Address - City:DELTON
Practice Address - State:MI
Practice Address - Zip Code:49046-8825
Practice Address - Country:US
Practice Address - Phone:269-623-1520
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2017-08-20
Last Update Date:2017-08-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI2601001854207PS0010X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207PS0010XAllopathic & Osteopathic PhysiciansEmergency MedicineSports Medicine