Healthcare Provider Details

I. General information

NPI: 1235105404
Provider Name (Legal Business Name): MICHAEL STEPHEN KOCH MS, ATC
Entity Type: Individual
Gender: Male
Sole Proprietor: X

II. Dates (important events)

Enumeration Date: 02/27/2006
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

102 W KENWOOD AVE
DECATUR IL
62526-4300
US

IV. Provider business mailing address

3137 COLORADO DR
DECATUR IL
62526-2332
US

V. Phone/Fax

Practice location:
  • Phone: 217-876-6820
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code2255A2300X
TaxonomyAthletic Trainer
License Number96002099
License Number StateIL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: