Healthcare Provider Details

I. General information

NPI: 1306815915
Provider Name (Legal Business Name): CAROLYN G KOCHERT MD
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 03/16/2006
Last Update Date: 12/23/2011
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3218 DAUGHERTY DRIVE SUITE 110
LAFAYETTE IN
47909-3997
US

IV. Provider business mailing address

3218 DAUGHERTY DR SUITE 110
LAFAYETTE IN
47909-3997
US

V. Phone/Fax

Practice location:
  • Phone: 765-446-5055
  • Fax: 765-446-5057
Mailing address:
  • Phone: 765-446-5055
  • Fax: 765-446-5057

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code207L00000X
TaxonomyAnesthesiology Physician
License Number01031275A
License Number StateIN
# 2
Primary TaxonomyY
Taxonomy Code207LP2900X
TaxonomyPain Medicine (Anesthesiology) Physician
License Number01031275A
License Number StateIN

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: