Healthcare Provider Details

I. General information

NPI: 1568670149
Provider Name (Legal Business Name): SPENCER ROBISON KOCH M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 05/18/2007
Last Update Date: 08/30/2013
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

5333 MCAULEY DR SUITE 6016
YPSILANTI MI
48197-1014
US

IV. Provider business mailing address

5333 MCAULEY DR SUITE 6016
YPSILANTI MI
48197-1014
US

V. Phone/Fax

Practice location:
  • Phone: 734-712-8350
  • Fax: 734-712-8351
Mailing address:
  • Phone: 734-712-8350
  • Fax: 734-712-8351

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code2085R0202X
TaxonomyDiagnostic Radiology Physician
License Number4301086442
License Number StateMI
# 2
Primary TaxonomyN
Taxonomy Code2085D0003X
TaxonomyDiagnostic Neuroimaging (Radiology) Physician
License Number163466
License Number StateNC

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: