Healthcare Provider Details

I. General information

NPI: 1275554750
Provider Name (Legal Business Name): RICHARD A KOCH M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/21/2006
Last Update Date: 10/18/2011
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

125 DUNN RD
FLORISSANT MO
63031-8007
US

IV. Provider business mailing address

PO BOX 411515
SAINT LOUIS MO
63141-3515
US

V. Phone/Fax

Practice location:
  • Phone: 314-921-9555
  • Fax: 314-921-5525
Mailing address:
  • Phone: 314-333-6750
  • Fax: 314-432-0178

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code2085R0202X
TaxonomyDiagnostic Radiology Physician
License NumberR9D82
License Number StateMO
# 2
Primary TaxonomyN
Taxonomy Code2085R0202X
TaxonomyDiagnostic Radiology Physician
License Number036070767
License Number StateIL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: