Healthcare Provider Details

I. General information

NPI: 1063906352
Provider Name (Legal Business Name): SUSANNAH K KOCH MD
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/19/2018
Last Update Date: 08/02/2022
Certification Date: 08/02/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1414 CROSS ST STE 240
SHILOH IL
62269-2988
US

IV. Provider business mailing address

1414 CROSS ST STE 240
SHILOH IL
62269-2988
US

V. Phone/Fax

Practice location:
  • Phone: 618-607-3800
  • Fax:
Mailing address:
  • Phone: 618-607-3800
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code207V00000X
TaxonomyObstetrics & Gynecology Physician
License Number2018019106
License Number StateMO
# 2
Primary TaxonomyY
Taxonomy Code207V00000X
TaxonomyObstetrics & Gynecology Physician
License Number036161310
License Number StateIL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: