=====================================================
General NPI Number Information
=====================================================
NPI Number | 1972798049
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | KEVIN G. KOTH D.O.
-----------------------------------------------------
Gender | Male
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 09/11/2007
-----------------------------------------------------
Last Update Date | 03/14/2024
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 12866 TROXLER AVE
-----------------------------------------------------
City | HIGHLAND
-----------------------------------------------------
State | IL
-----------------------------------------------------
Zip | 62249-2806
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 618-900-1070
-----------------------------------------------------
Fax | 833-992-2437
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | PO BOX 160
-----------------------------------------------------
City | TROY
-----------------------------------------------------
State | IL
-----------------------------------------------------
Zip | 62294-0160
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 618-900-1070
-----------------------------------------------------
Fax | 833-992-2437
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 207X00000X
-----------------------------------------------------
Taxonomy Name | Orthopaedic Surgery Physician
-----------------------------------------------------
License Number | 03476
-----------------------------------------------------
License Number State | KY
-----------------------------------------------------
Taxonomy #2
-----------------------------------------------------
Taxonomy Code | 207X00000X
-----------------------------------------------------
Taxonomy Name | Orthopaedic Surgery Physician
-----------------------------------------------------
License Number | 02003992A
-----------------------------------------------------
License Number State | IN
-----------------------------------------------------
Taxonomy #3
-----------------------------------------------------
Taxonomy Code | 207XS0117X
-----------------------------------------------------
Taxonomy Name | Orthopaedic Surgery of the Spine Physician
-----------------------------------------------------
License Number | 03476
-----------------------------------------------------
License Number State | KY
-----------------------------------------------------
Taxonomy #4
-----------------------------------------------------
Taxonomy Code | 207X00000X
-----------------------------------------------------
Taxonomy Name | Orthopaedic Surgery Physician
-----------------------------------------------------
License Number | 036132543
-----------------------------------------------------
License Number State | IL
-----------------------------------------------------