Provider Demographics
NPI:1821275256
Name:KOOCK E JUNG MD PC
Entity Type:Organization
Organization Name:KOOCK E JUNG MD PC
Other - Org Name:PSYCHOTHERAPY CENTER
Other - Org Type:Other Name
Authorized Official - Title/Position:OFFICE MANAGER
Authorized Official - Prefix:
Authorized Official - First Name:KOOCK
Authorized Official - Middle Name:E
Authorized Official - Last Name:JUNG
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:518-793-1160
Mailing Address - Street 1:597 BAY ROAD
Mailing Address - Street 2:
Mailing Address - City:QUEENSBURY
Mailing Address - State:NY
Mailing Address - Zip Code:12804
Mailing Address - Country:US
Mailing Address - Phone:518-793-1160
Mailing Address - Fax:518-793-1255
Practice Address - Street 1:597 BAY ROAD
Practice Address - Street 2:
Practice Address - City:QUEENSBURY
Practice Address - State:NY
Practice Address - Zip Code:12804
Practice Address - Country:US
Practice Address - Phone:518-793-1160
Practice Address - Fax:518-793-1255
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-01-29
Last Update Date:2011-12-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes2084P0800XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyPsychiatryGroup - Multi-Specialty
No1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinicalGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
AA1374Medicare PIN