Healthcare Provider Details

I. General information

NPI: 1710078985
Provider Name (Legal Business Name): ROBERT ANTHONY KOCH D.C.P.C.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 09/27/2006
Last Update Date: 08/19/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

14720 FORT ST
SOUTHGATE MI
48195-1217
US

IV. Provider business mailing address

14720 FORT ST
SOUTHGATE MI
48195-1217
US

V. Phone/Fax

Practice location:
  • Phone: 734-281-2400
  • Fax: 734-281-1795
Mailing address:
  • Phone: 734-281-2400
  • Fax: 734-281-1795

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code111N00000X
TaxonomyChiropractor
License Number2301004639
License Number StateMI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: