Provider Demographics
NPI:1467436436
Name:KOCH, STANLEY W (MD)
Entity Type:Individual
Prefix:DR
First Name:STANLEY
Middle Name:W
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 1:411 MAXINE DR
Mailing Address - Street 2:
Mailing Address - City:MORTON
Mailing Address - State:IL
Mailing Address - Zip Code:61550-2495
Mailing Address - Country:US
Mailing Address - Phone:309-263-2411
Mailing Address - Fax:309-263-2208
Practice Address - Street 1:411 MAXINE DR
Practice Address - Street 2:
Practice Address - City:MORTON
Practice Address - State:IL
Practice Address - Zip Code:61550-2495
Practice Address - Country:US
Practice Address - Phone:309-263-2411
Practice Address - Fax:309-263-2208
Is Sole Proprietor?:Yes
Enumeration Date:2005-12-02
Last Update Date:2010-08-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL036060959207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL371398455Medicaid
IL371398455OtherTAX ID#
IL371398455OtherTAX ID#
IL371398455Medicaid