Healthcare Provider Details

I. General information

NPI: 1972798049
Provider Name (Legal Business Name): KEVIN G. KOTH D.O.
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 09/11/2007
Last Update Date: 03/14/2024
Certification Date: 03/14/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

12866 TROXLER AVE
HIGHLAND IL
62249-2806
US

IV. Provider business mailing address

PO BOX 160
TROY IL
62294-0160
US

V. Phone/Fax

Practice location:
  • Phone: 618-900-1070
  • Fax: 833-992-2437
Mailing address:
  • Phone: 618-900-1070
  • Fax: 833-992-2437

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code207X00000X
TaxonomyOrthopaedic Surgery Physician
License Number03476
License Number StateKY
# 2
Primary TaxonomyN
Taxonomy Code207X00000X
TaxonomyOrthopaedic Surgery Physician
License Number02003992A
License Number StateIN
# 3
Primary TaxonomyN
Taxonomy Code207XS0117X
TaxonomyOrthopaedic Surgery of the Spine Physician
License Number03476
License Number StateKY
# 4
Primary TaxonomyY
Taxonomy Code207X00000X
TaxonomyOrthopaedic Surgery Physician
License Number036132543
License Number StateIL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: