=====================================================
General NPI Number Information
=====================================================
NPI Number | 1548285117
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | PARKERSBURG SURGICAL ASSOCIATES, PLLC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 07/13/2006
-----------------------------------------------------
Last Update Date | 08/11/2011
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 800 GRAND CENTRAL MALL SUITE 2
-----------------------------------------------------
City | VIENNA
-----------------------------------------------------
State | WV
-----------------------------------------------------
Zip | 26105-4131
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 304-865-4345
-----------------------------------------------------
Fax | 304-420-5995
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 800 GRAND CENTRAL MALL SUITE 2
-----------------------------------------------------
City | VIENNA
-----------------------------------------------------
State | WV
-----------------------------------------------------
Zip | 26105-4131
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 304-865-4345
-----------------------------------------------------
Fax | 304-420-5995
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | PARTNER
-----------------------------------------------------
Name | DR. JOHN KEVIN KOCH
-----------------------------------------------------
Credential | M.D.
-----------------------------------------------------
Telephone | 304-865-4345
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 208600000X
-----------------------------------------------------
Taxonomy Name | Surgery Physician
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------