Provider Demographics
NPI:1740398924
Name:PITTSBURG FAMILY MEDICINE LLC
Entity Type:Organization
Organization Name:PITTSBURG FAMILY MEDICINE LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PHYSICIAN
Authorized Official - Prefix:
Authorized Official - First Name:DANIEL
Authorized Official - Middle Name:J
Authorized Official - Last Name:KOEHN
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:620-235-1043
Mailing Address - Street 1:2401 SOUTH TUCKER AVE
Mailing Address - Street 2:STE 2
Mailing Address - City:PITTSBURGH
Mailing Address - State:KS
Mailing Address - Zip Code:66762
Mailing Address - Country:US
Mailing Address - Phone:620-235-1043
Mailing Address - Fax:620-231-6555
Practice Address - Street 1:2401 SOUTH TUCKER AVE
Practice Address - Street 2:STE 2
Practice Address - City:PITTSBURGH
Practice Address - State:KS
Practice Address - Zip Code:66762
Practice Address - Country:US
Practice Address - Phone:620-235-1043
Practice Address - Fax:620-231-6555
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-08-28
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KS23565207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
E24102Medicare UPIN
KS102531Medicare ID - Type UnspecifiedINDIV