1568470607 NPI number — MRS. KRISTINA JULIE KOCH PT

Table of content: MRS. KRISTINA JULIE KOCH PT (NPI 1568470607)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1568470607 NPI number — MRS. KRISTINA JULIE KOCH PT

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
KOCH
Provider First Name:
KRISTINA
Provider Middle Name:
JULIE
Provider Name Prefix Text:
MRS.
Provider Name Suffix Text:
Provider Credential Text:
PT
Provider Gender Code:
F

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1568470607
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
07/08/2007
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
208 N MAIN ST.
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
TROY GROVE
Provider Business Mailing Address State Name:
IL
Provider Business Mailing Address Postal Code:
61372
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
815-538-5137
Provider Business Mailing Address Fax Number:
815-538-5137

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
208 N MAIN ST.
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
TROY GROVE
Provider Business Practice Location Address State Name:
IL
Provider Business Practice Location Address Postal Code:
61372
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
815-538-5137
Provider Business Practice Location Address Fax Number:
815-538-5137
Provider Enumeration Date:
08/04/2006

Additional Information

Authorized Official

Authorized Official Last Name:
Authorized Official First Name:
Authorized Official Middle Name:
Authorized Official Title or Position:
Authorized Official Telephone Number:

Provider Taxonomy Codes

  • Taxonomy code: 225100000X , registered in the state of IL ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)

  • Identifier: 0005032019 . This is a "BCBS PROVIDER NUMBER" identifier , issued by the state of ( IL ) . This identifiers is of the category "OTHER".




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