Healthcare Provider Details

I. General information

NPI: 1629069497
Provider Name (Legal Business Name): MARC E. KOCH MD, MBA
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 11/02/2005
Last Update Date: 06/01/2020
Certification Date: 06/01/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

450 MAMARONECK AVE STE 201
HARRISON NY
10528-2436
US

IV. Provider business mailing address

450 MAMARONECK AVE STE 201
HARRISON NY
10528-2436
US

V. Phone/Fax

Practice location:
  • Phone: 914-637-3511
  • Fax: 914-560-2227
Mailing address:
  • Phone: 914-637-3511
  • Fax: 914-560-2227

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code207LP2900X
TaxonomyPain Medicine (Anesthesiology) Physician
License NumberMD424232
License Number StatePA
# 2
Primary TaxonomyN
Taxonomy Code208VP0000X
TaxonomyPain Medicine Physician
License NumberMD424233
License Number StatePA
# 3
Primary TaxonomyY
Taxonomy Code207L00000X
TaxonomyAnesthesiology Physician
License Number192817
License Number StateNY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: