Provider Demographics
NPI:1720859150
Name:KOCH, THOMAS MICHAEL (PA-C)
Entity Type:Individual
Prefix:
First Name:THOMAS
Middle Name:MICHAEL
Last Name:KOCH
Suffix:
Gender:M
Credentials:PA-C
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1242 N BOSWORTH AVE APT 1F
Mailing Address - Street 2:
Mailing Address - City:CHICAGO
Mailing Address - State:IL
Mailing Address - Zip Code:60642-3356
Mailing Address - Country:US
Mailing Address - Phone:847-276-6425
Mailing Address - Fax:
Practice Address - Street 1:4646 N MARINE DR
Practice Address - Street 2:
Practice Address - City:CHICAGO
Practice Address - State:IL
Practice Address - Zip Code:60640-5759
Practice Address - Country:US
Practice Address - Phone:773-878-8700
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2024-01-15
Last Update Date:2024-01-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedical