Provider Demographics
NPI:1134210834
Name:KOECHER, BRIAN STEVEN (DO)
Entity type:Individual
Prefix:
First Name:BRIAN
Middle Name:STEVEN
Last Name:KOECHER
Suffix:
Gender:M
Credentials:DO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:220 E LAKE ST
Mailing Address - Street 2:SUITE 100
Mailing Address - City:ADDISON
Mailing Address - State:IL
Mailing Address - Zip Code:60101-2887
Mailing Address - Country:US
Mailing Address - Phone:630-516-0434
Mailing Address - Fax:630-516-0419
Practice Address - Street 1:220 E LAKE ST
Practice Address - Street 2:SUITE 100
Practice Address - City:ADDISON
Practice Address - State:IL
Practice Address - Zip Code:60101-2887
Practice Address - Country:US
Practice Address - Phone:630-516-0434
Practice Address - Fax:630-516-0419
Is Sole Proprietor?:No
Enumeration Date:2006-09-27
Last Update Date:2012-12-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL036-107694207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
ILK21884Medicare ID - Type Unspecified
ILH94001Medicare UPIN