Healthcare Provider Details

I. General information

NPI: 1750712485
Provider Name (Legal Business Name): KOCH MEDICINE LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 12/05/2013
Last Update Date: 12/02/2015
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4447 S CANYON RD SUITE 6
RAPID CITY SD
57702
US

IV. Provider business mailing address

PO BOX 346
RAPID CITY SD
57709-0346
US

V. Phone/Fax

Practice location:
  • Phone: 605-721-6426
  • Fax: 605-721-5515
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License Number4447
License Number StateSD

VIII. Authorized Official

Name: SHERRI KOCH
Title or Position: PRESIDENT
Credential: MD
Phone: 605-791-3974