Basic Information
Provider Information | |||||||||
NPI: | 1528067527 | ||||||||
EntityType: | 1 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: |   | ||||||||
LastName: | KOCH | ||||||||
FirstName: | GEORGE | ||||||||
MiddleName: | ANTHONY | ||||||||
NamePrefix: | DR. | ||||||||
NameSuffix: |   | ||||||||
Credential: | DO | ||||||||
OtherOrganizationName: |   | ||||||||
OtherOrganizationType: |   | ||||||||
OtherLastName: |   | ||||||||
OtherFirstName: |   | ||||||||
OtherMiddleName: |   | ||||||||
OtherNamePrefix: |   | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: |   | ||||||||
OtherLastNameType: |   | ||||||||
Mailing Information | |||||||||
Address1: | 54 HOSPITAL DR | ||||||||
Address2: |   | ||||||||
City: | OSAGE BEACH | ||||||||
State: | MO | ||||||||
PostalCode: | 650653050 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: |   | ||||||||
FaxNumber: |   | ||||||||
Practice Location | |||||||||
Address1: | 54 HOSPITAL DR | ||||||||
Address2: |   | ||||||||
City: | OSAGE BEACH | ||||||||
State: | MO | ||||||||
PostalCode: | 650653050 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 5733022287 | ||||||||
FaxNumber: | 5733022241 | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 07/20/2005 | ||||||||
LastUpdateDate: | 05/01/2008 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: | M | ||||||||
AuthorizedOfficialLastName: |   | ||||||||
AuthorizedOfficialFirstName: |   | ||||||||
AuthorizedOfficialMiddleName: |   | ||||||||
AuthorizedOfficialTitleorPosition: |   | ||||||||
AuthorizedOfficialTelephone: |   | ||||||||
IsSoleProprietor: | N | ||||||||
IsOrganizationSubpart: |   | ||||||||
ParentOrganizationLBN: |   | ||||||||
AuthorizedOfficialNamePrefix: |   | ||||||||
AuthorizedOfficialNameSuffix: |   | ||||||||
AuthorizedOfficialCredential: |   | ||||||||
NPICertificationDate: |   |
Taxonomy Information
Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 208M00000X | 2002021772 | MO | Y |   | Allopathic & Osteopathic Physicians | Hospitalist |   | 207RI0200X | 2002021772 | MO | N |   | Allopathic & Osteopathic Physicians | Internal Medicine | Infectious Disease |
ID Information
ID | Type | State | Issuer | Description | P00171341 | 01 | MO | RAILROAD MEDICARE | OTHER | 245978408 | 05 | MO |   | MEDICAID |