MEDICARE: THOMAS MICHAEL KOCH PA-C

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	363A00000X	Physician Assistant	085.010261	IL
2	363AM0700X	Medical Physician Assistant

General Provider Information

NPI Number	:	1720859150
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	THOMAS MICHAEL KOCH PA-C

Provider Business Mailing Address
First Line	:	1242 N BOSWORTH AVE APT 1F
Second Line	:
City	:	CHICAGO
State	:	IL
Zip	:	60642-3356
Country	:	US
Telephone Number	:	847-276-6425
Fax Number	:

Provider Business Practice Location Address
First Line	:	4646 N MARINE DR
Second Line	:
City	:	CHICAGO
State	:	IL
Zip	:	60640-5759
Country	:	US
Telephone Number	:	773-878-8700
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	01/15/2024
Last Update Date	:	03/06/2026

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