Healthcare Provider Details

I. General information

NPI: 1467436436
Provider Name (Legal Business Name): STANLEY W KOCH MD
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 12/02/2005
Last Update Date: 08/23/2010
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

411 MAXINE DR
MORTON IL
61550-2495
US

IV. Provider business mailing address

411 MAXINE DR
MORTON IL
61550-2495
US

V. Phone/Fax

Practice location:
  • Phone: 309-263-2411
  • Fax: 309-263-2208
Mailing address:
  • Phone: 309-263-2411
  • Fax: 309-263-2208

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License Number036060959
License Number StateIL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: