Healthcare Provider Details

I. General information

NPI: 1558333997
Provider Name (Legal Business Name): ROBERT EDWARD KOCH CRNA
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 02/01/2006
Last Update Date: 02/18/2014
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3125 DR RUSSELL SMITH WAY
CARTHAGE MO
64836-7402
US

IV. Provider business mailing address

10917 GUM RD
CARTHAGE MO
64836-9529
US

V. Phone/Fax

Practice location:
  • Phone: 417-359-2653
  • Fax: 417-358-4612
Mailing address:
  • Phone: 417-237-0588
  • Fax: 417-237-0588

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code367500000X
TaxonomyCertified Registered Nurse Anesthetist
License Number063623
License Number StateMO

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: