Healthcare Provider Details

I. General information

NPI: 1588649925
Provider Name (Legal Business Name): KENNETH KOCH MD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 12/08/2005
Last Update Date: 05/12/2008
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

MEDICAL CENTER BLVD
WINSTON SALEM NC
27157-0001
US

IV. Provider business mailing address

PO BOX 344
WINSTON SALEM NC
27102-0344
US

V. Phone/Fax

Practice location:
  • Phone: 336-716-2255
  • Fax:
Mailing address:
  • Phone: 336-716-2255
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207RG0100X
TaxonomyGastroenterology Physician
License Number200201425
License Number StateNC

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: