Basic Information
| Provider Information | |||||||||
| NPI: | 1932722766 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | KOYACK | ||||||||
| FirstName: | MICHAEL | ||||||||
| MiddleName: | JOHN | ||||||||
| NamePrefix: | MR. | ||||||||
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| Credential: | LAT, ATC, PES | ||||||||
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| Mailing Information | |||||||||
| Address1: | 500 TRIPOLI ST APT 202 | ||||||||
| Address2: | |||||||||
| City: | PITTSBURGH | ||||||||
| State: | PA | ||||||||
| PostalCode: | 152124884 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7168637710 | ||||||||
| FaxNumber: | |||||||||
| Practice Location | |||||||||
| Address1: | 3200 S WATER ST | ||||||||
| Address2: | |||||||||
| City: | PITTSBURGH | ||||||||
| State: | PA | ||||||||
| PostalCode: | 152032307 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8559377678 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 05/27/2020 | ||||||||
| LastUpdateDate: | 05/27/2020 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 05/27/2020 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 2255A2300X | RT004355 | PA | Y | Respiratory, Developmental, Rehabilitative and Restorative Service Providers | Specialist/Technologist | Athletic Trainer |
No ID Information.