Provider Demographics
NPI:1487623286
Name:KOCH, PAUL W (MD)
Entity type:Individual
Prefix:
First Name:PAUL
Middle Name:W
Last Name:KOCH
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:24920 FAIRMOUNT DR
Mailing Address - Street 2:
Mailing Address - City:DEARBORN
Mailing Address - State:MI
Mailing Address - Zip Code:48124-1584
Mailing Address - Country:US
Mailing Address - Phone:313-274-6579
Mailing Address - Fax:
Practice Address - Street 1:159 KERCHEVAL AVE.
Practice Address - Street 2:
Practice Address - City:GROSSE POINTE
Practice Address - State:MI
Practice Address - Zip Code:48236
Practice Address - Country:US
Practice Address - Phone:313-640-2300
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-03-15
Last Update Date:2022-11-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI4301052069207PE0004X
IL036110592207R00000X, 207P00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207P00000XAllopathic & Osteopathic PhysiciansEmergency Medicine
No207PE0004XAllopathic & Osteopathic PhysiciansEmergency MedicineEmergency Medical Services
No207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL3932056OtherBLUE SHEILD
IL036110592-2Medicaid
E81861Medicare UPIN
IL036110592-2Medicaid