Provider Demographics
NPI:1740229319
Name:KOCH, ROBERT WALTER (MD)
Entity Type:Individual
Prefix:
First Name:ROBERT
Middle Name:WALTER
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 1:1319 SMITHSON TRL
Mailing Address - Street 2:
Mailing Address - City:EADS
Mailing Address - State:TN
Mailing Address - Zip Code:38028-6902
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:1500 W POPLAR AVE
Practice Address - Street 2:
Practice Address - City:COLLIERVILLE
Practice Address - State:TN
Practice Address - Zip Code:38017-0601
Practice Address - Country:US
Practice Address - Phone:901-861-9000
Practice Address - Fax:
Is Sole Proprietor?:Not Answered
Enumeration Date:2006-06-06
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TN16195207P00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207P00000XAllopathic & Osteopathic PhysiciansEmergency Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
MS00125950Medicaid
TN3020046Medicaid
MS00125950Medicaid
TNA98374Medicare UPIN
TN3020046Medicaid