Provider Demographics
NPI:1104463819
Name:KOECH, GARY SYDNEY III
Entity type:Individual
Prefix:MR
First Name:GARY
Middle Name:SYDNEY
Last Name:KOECH
Suffix:III
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:675 N HIGHLAND AVE NE APT 303
Mailing Address - Street 2:
Mailing Address - City:ATLANTA
Mailing Address - State:GA
Mailing Address - Zip Code:30306-4673
Mailing Address - Country:US
Mailing Address - Phone:304-813-9399
Mailing Address - Fax:
Practice Address - Street 1:EMORY MIDTOWN- DAVIS FISCHER BLD 3RD FLOOR, RM 3245A
Practice Address - Street 2:550 PEACHTREE STREET, N.E.
Practice Address - City:ATLANTA
Practice Address - State:GA
Practice Address - Zip Code:30308
Practice Address - Country:US
Practice Address - Phone:404-686-7858
Practice Address - Fax:404-686-7841
Is Sole Proprietor?:Yes
Enumeration Date:2019-12-02
Last Update Date:2021-09-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GARN292038163W00000X, 363LA2100X
TX876479163W00000X
GAPENDING363LA2100X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LA2100XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerAcute Care
No163W00000XNursing Service ProvidersRegistered Nurse