Healthcare Provider Details

I. General information

NPI: 1720859150
Provider Name (Legal Business Name): THOMAS MICHAEL KOCH PA-C
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 01/15/2024
Last Update Date: 01/15/2024
Certification Date: 01/13/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4646 N MARINE DR
CHICAGO IL
60640-5759
US

IV. Provider business mailing address

1242 N BOSWORTH AVE APT 1F
CHICAGO IL
60642-3356
US

V. Phone/Fax

Practice location:
  • Phone: 773-878-8700
  • Fax:
Mailing address:
  • Phone: 847-276-6425
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363AM0700X
TaxonomyMedical Physician Assistant
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: