Provider Demographics
NPI:1477050664
Name:KOSHY, JIMMY
Entity type:Individual
Prefix:
First Name:JIMMY
Middle Name:
Last Name:KOSHY
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1605 E 13 MILE RD APT 104
Mailing Address - Street 2:
Mailing Address - City:MADISON HEIGHTS
Mailing Address - State:MI
Mailing Address - Zip Code:48071-5018
Mailing Address - Country:US
Mailing Address - Phone:586-864-6793
Mailing Address - Fax:
Practice Address - Street 1:1605 E 13 MILE RD APT 104
Practice Address - Street 2:
Practice Address - City:MADISON HEIGHTS
Practice Address - State:MI
Practice Address - Zip Code:48071-5018
Practice Address - Country:US
Practice Address - Phone:586-864-6793
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2018-04-12
Last Update Date:2018-04-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI5501013094225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist