1023269446 NPI number — MRS. ELIZABETH ALICE KOCH PA-C

Table of content: MRS. ELIZABETH ALICE KOCH PA-C (NPI 1023269446)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1023269446 NPI number — MRS. ELIZABETH ALICE KOCH PA-C

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
KOCH
Provider First Name:
ELIZABETH
Provider Middle Name:
ALICE
Provider Name Prefix Text:
MRS.
Provider Name Suffix Text:
Provider Credential Text:
PA-C
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:
1023269446
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
02/01/2017
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
1 WESTBROOK CORPORATE CTR
Provider Second Line Business Mailing Address:
STE 800
Provider Business Mailing Address City Name:
WESTCHESTER
Provider Business Mailing Address State Name:
IL
Provider Business Mailing Address Postal Code:
60154-5701
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
708-343-3566
Provider Business Mailing Address Fax Number:

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
1 WESTBROOK CORPORATE CTR
Provider Second Line Business Practice Location Address:
STE 800
Provider Business Practice Location Address City Name:
WESTCHESTER
Provider Business Practice Location Address State Name:
IL
Provider Business Practice Location Address Postal Code:
60154-5701
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
708-343-3566
Provider Business Practice Location Address Fax Number:
Provider Enumeration Date:
10/03/2008

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: 363AS0400X , with the licence number:  085003308 , 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: 085003308 , issued by the state of ( IL ) . This identifiers is of the category "MEDICAID".
  • Identifier: 1003856758 . This is a "MEDICARE DUPAGE COUNTY" identifier , issued by the state of ( IL ) . This identifiers is of the category "OTHER".
  • Identifier: 1770524670 . This is a "MEDICARE ID- COOK CO" identifier , issued by the state of ( IL ) . This identifiers is of the category "OTHER".




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