Provider Demographics
NPI:1558333997
Name:KOCH, ROBERT EDWARD (CRNA)
Entity Type:Individual
Prefix:
First Name:ROBERT
Middle Name:EDWARD
Last Name:KOCH
Suffix:
Gender:M
Credentials:CRNA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:10917 GUM RD
Mailing Address - Street 2:
Mailing Address - City:CARTHAGE
Mailing Address - State:MO
Mailing Address - Zip Code:64836-9529
Mailing Address - Country:US
Mailing Address - Phone:417-237-0588
Mailing Address - Fax:417-237-0588
Practice Address - Street 1:3125 DR RUSSELL SMITH WAY
Practice Address - Street 2:
Practice Address - City:CARTHAGE
Practice Address - State:MO
Practice Address - Zip Code:64836-7402
Practice Address - Country:US
Practice Address - Phone:417-359-2653
Practice Address - Fax:417-358-4612
Is Sole Proprietor?:No
Enumeration Date:2006-02-01
Last Update Date:2014-02-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO063623367500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes367500000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Anesthetist, Certified Registered
Provider Identifiers
StateIdentifier IDID TypeIssuer
MOP01158529OtherRAIL ROAD MEDICARE
MOMA3832023Medicare PIN