Primary | Taxonomy Code | Taxonomy Specialty | License Number | License State |
---|---|---|---|---|
Y | 207QG0300X | Family Doctor - Geriatric Medicine | MD018756E | PA |
NPI | 1033114400 |
---|---|
Provider Name | Royal Koeller |
First Address | Johnstown, PA 15905-4305 |
Second Address | Johnstown, PA 15905-4305 |
Gender | M |
NPI Entity type | Individual |
Is Sole Proprietor | No |
Is Organization Subpart | N/A |
Enumeration Date | 14/06/2005 |
Last Update Date | 30/04/2013 |
IDENTIFIER | TYPE / CODE | IDENTIFIER STATE |
---|---|---|
000692711 | (05) | PA |
B36888 | (02) |