Healthcare Provider Details

I. General information

NPI: 1851204234
Provider Name (Legal Business Name): MATTHEW KOCH
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 09/25/2026
Last Update Date: 09/25/2026
Certification Date: 09/25/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

200 S 23RD AVE STE F1
BOZEMAN MT
59718-3965
US

IV. Provider business mailing address

19205 MOUNT AIREY RD
BROOKEVILLE MD
20833-2720
US

V. Phone/Fax

Practice location:
  • Phone: 240-688-7958
  • Fax: 301-260-1796
Mailing address:
  • Phone: 240-688-7958
  • Fax: 301-260-1796

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code390200000X
TaxonomyStudent in an Organized Health Care Education/Training Program
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: