Provider Demographics
NPI:1194507772
Name:KOIVISTO, MAX (NRAEMT)
Entity type:Individual
Prefix:MR
First Name:MAX
Middle Name:
Last Name:KOIVISTO
Suffix:
Gender:M
Credentials:NRAEMT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:557 MAIN ST
Mailing Address - Street 2:
Mailing Address - City:BECKET
Mailing Address - State:MA
Mailing Address - Zip Code:01223-3252
Mailing Address - Country:US
Mailing Address - Phone:413-623-5027
Mailing Address - Fax:413-623-2062
Practice Address - Street 1:629 JACOBS LADDER ROAD
Practice Address - Street 2:
Practice Address - City:BECKET
Practice Address - State:MA
Practice Address - Zip Code:01223
Practice Address - Country:US
Practice Address - Phone:413-623-5027
Practice Address - Fax:413-623-2062
Is Sole Proprietor?:No
Enumeration Date:2023-10-18
Last Update Date:2023-10-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MAA0900516146M00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes146M00000XEmergency Medical Service ProvidersEmergency Medical Technician, Intermediate