Provider Demographics
NPI:1275554750
Name:KOCH, RICHARD A (MD)
Entity Type:Individual
Prefix:
First Name:RICHARD
Middle Name:A
Last Name:KOCH
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 411515
Mailing Address - Street 2:
Mailing Address - City:SAINT LOUIS
Mailing Address - State:MO
Mailing Address - Zip Code:63141-3515
Mailing Address - Country:US
Mailing Address - Phone:314-333-6750
Mailing Address - Fax:314-432-0178
Practice Address - Street 1:125 DUNN RD
Practice Address - Street 2:
Practice Address - City:FLORISSANT
Practice Address - State:MO
Practice Address - Zip Code:63031-8007
Practice Address - Country:US
Practice Address - Phone:314-921-9555
Practice Address - Fax:314-921-5525
Is Sole Proprietor?:No
Enumeration Date:2006-07-21
Last Update Date:2011-10-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MOR9D822085R0202X
IL0360707672085R0202X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2085R0202XAllopathic & Osteopathic PhysiciansRadiologyDiagnostic Radiology
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL036070767Medicaid
MO300102469OtherRAILROAD MEDICARE
MO202115408Medicaid
MO300102478OtherRAILROAD MEDICARE
MO202115408Medicaid
MO300102478OtherRAILROAD MEDICARE
MO013013061Medicare ID - Type UnspecifiedMO MEDICARE
ILL79223Medicare ID - Type UnspecifiedIL MEDICARE