Healthcare Provider Details

I. General information

NPI: 1326031337
Provider Name (Legal Business Name): MARK KOCH RN
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 08/24/2005
Last Update Date: 03/26/2008
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3000 MACK RD
FAIRFIELD OH
45014-5335
US

IV. Provider business mailing address

11490 SPRINGFIELD PIKE
CINCINNATI OH
45246-3524
US

V. Phone/Fax

Practice location:
  • Phone: 513-870-7000
  • Fax:
Mailing address:
  • Phone: 513-672-3309
  • Fax: 513-672-3323

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code367500000X
TaxonomyCertified Registered Nurse Anesthetist
License Number172619
License Number StateOH

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: