Healthcare Provider Details

I. General information

NPI: 1528148061
Provider Name (Legal Business Name): DAVID GLENN KOCH M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 10/17/2006
Last Update Date: 07/13/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

171 ASHLEY AVE
CHARLESTON SC
29425-0001
US

IV. Provider business mailing address

96 JONATHAN LUCAS ST SUITE 210 CLINICAL SCIENCE BUILDING, P.O. BOX 250327
CHARLESTON SC
29425-8900
US

V. Phone/Fax

Practice location:
  • Phone: 843-792-1414
  • Fax:
Mailing address:
  • Phone: 843-792-6901
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207RG0100X
TaxonomyGastroenterology Physician
License Number26893
License Number StateSC
# 2
Primary TaxonomyN
Taxonomy Code207RI0008X
TaxonomyHepatology Physician
License Number26893
License Number StateSC

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: