Healthcare Provider Details

I. General information

NPI: 1689649337
Provider Name (Legal Business Name): JAMES MICHAEL KOCH M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 02/17/2006
Last Update Date: 03/26/2019
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

20776 BRANTLEY RD
SHAKER HEIGHTS OH
44122-1930
US

IV. Provider business mailing address

20776 BRANTLEY RD
SHAKER HEIGHTS OH
44122-1930
US

V. Phone/Fax

Practice location:
  • Phone: 216-296-2108
  • Fax:
Mailing address:
  • Phone: 216-296-2108
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207RC0000X
TaxonomyCardiovascular Disease Physician
License Number35054940
License Number StateOH

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: