Basic Information
| Provider Information | |||||||||
| NPI: | 1326350679 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | FEEKO | ||||||||
| FirstName: | KRISTOFER | ||||||||
| MiddleName: | J | ||||||||
| NamePrefix: | DR. | ||||||||
| NameSuffix: | |||||||||
| Credential: | D.O. | ||||||||
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| Mailing Information | |||||||||
| Address1: | 25 S 9TH ST FL 1 | ||||||||
| Address2: | |||||||||
| City: | PHILADELPHIA | ||||||||
| State: | PA | ||||||||
| PostalCode: | 191074408 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2159551200 | ||||||||
| FaxNumber: | 2159236808 | ||||||||
| Practice Location | |||||||||
| Address1: | 25 S 9TH ST FL 1 | ||||||||
| Address2: | |||||||||
| City: | PHILADELPHIA | ||||||||
| State: | PA | ||||||||
| PostalCode: | 191074408 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2159551200 | ||||||||
| FaxNumber: | 2159236808 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 07/01/2010 | ||||||||
| LastUpdateDate: | 12/19/2018 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | Y | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 2081P0301X | OS016535 | PA | N | 208100000X | OS016535 | PA | Y | Allopathic & Osteopathic Physicians | Physical Medicine & Rehabilitation |
ID Information
| ID | Type | State | Issuer | Description | 0364975 | 05 | NJ | MEDICAID | 102847316 0001 | 05 | PA | MEDICAID |