Healthcare Provider Details

I. General information

NPI: 1487623286
Provider Name (Legal Business Name): PAUL W. KOCH M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 03/15/2006
Last Update Date: 11/27/2022
Certification Date: 11/27/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

159 KERCHEVAL AVE.
GROSSE POINTE MI
48236
US

IV. Provider business mailing address

24920 FAIRMOUNT DR
DEARBORN MI
48124-1584
US

V. Phone/Fax

Practice location:
  • Phone: 313-640-2300
  • Fax:
Mailing address:
  • Phone: 313-274-6579
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code207PE0004X
TaxonomyEmergency Medical Services (Emergency Medicine) Physician
License Number4301052069
License Number StateMI
# 2
Primary TaxonomyN
Taxonomy Code207R00000X
TaxonomyInternal Medicine Physician
License Number036110592
License Number StateIL
# 3
Primary TaxonomyY
Taxonomy Code207P00000X
TaxonomyEmergency Medicine Physician
License Number036110592
License Number StateIL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: