Healthcare Provider Details

I. General information

NPI: 1225287618
Provider Name (Legal Business Name): STEVEN M KOCH ATC
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 09/10/2008
Last Update Date: 09/10/2008
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1 UNIVERSITY CIR
MACOMB IL
61455-1367
US

IV. Provider business mailing address

553 RIVER RUN DR
MACOMB IL
61455-1173
US

V. Phone/Fax

Practice location:
  • Phone: 309-298-2340
  • Fax:
Mailing address:
  • Phone: 309-333-2860
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code2255A2300X
TaxonomyAthletic Trainer
License Number096002463
License Number StateIL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: