Provider Demographics
NPI:1851325252
Name:KOCH, RUTH E (NPP)
Entity Type:Individual
Prefix:
First Name:RUTH
Middle Name:E
Last Name:KOCH
Suffix:
Gender:F
Credentials:NPP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:31 INDUSTRIAL BOULEVARD
Mailing Address - Street 2:YAPHANK CENTER
Mailing Address - City:MEDFORD
Mailing Address - State:NY
Mailing Address - Zip Code:11763
Mailing Address - Country:US
Mailing Address - Phone:631-924-4411
Mailing Address - Fax:631-924-4454
Practice Address - Street 1:31 INDUSTRIAL BOULEVARD
Practice Address - Street 2:YAPHANK CENTER
Practice Address - City:MEDFORD
Practice Address - State:NY
Practice Address - Zip Code:11763
Practice Address - Country:US
Practice Address - Phone:631-924-4411
Practice Address - Fax:631-924-4454
Is Sole Proprietor?:Yes
Enumeration Date:2006-07-10
Last Update Date:2010-06-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NYF400122363LP0808X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LP0808XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPsychiatric/Mental Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY01634124Medicaid
NY007021Medicare UPIN