Healthcare Provider Details

I. General information

NPI: 1568857316
Provider Name (Legal Business Name): KIRSTEN KOCH MD
Entity Type: Individual
Gender: Female
Sole Proprietor: N

Provider Other Name: KIRSTEN LANGE

II. Dates (important events)

Enumeration Date: 03/30/2015
Last Update Date: 10/29/2020
Certification Date: 10/29/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3805 EDWARDS RD STE 360
CINCINNATI OH
45209
US

IV. Provider business mailing address

3805 EDWARDS RD STE 360
CINCINNATI OH
45209-1934
US

V. Phone/Fax

Practice location:
  • Phone: 513-871-7848
  • Fax: 513-871-3278
Mailing address:
  • Phone: 513-871-7848
  • Fax: 513-871-3278

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License Number35-133807
License Number StateOH

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: