Provider Demographics
NPI:1619327848
Name:KOCH, KELSEY ELYCE (MD)
Entity type:Individual
Prefix:
First Name:KELSEY
Middle Name:ELYCE
Last Name:KOCH
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2500 N STATE ST
Mailing Address - Street 2:
Mailing Address - City:JACKSON
Mailing Address - State:MS
Mailing Address - Zip Code:39216-4500
Mailing Address - Country:US
Mailing Address - Phone:601-815-1331
Mailing Address - Fax:
Practice Address - Street 1:971 LAKELAND DR STE 657
Practice Address - Street 2:
Practice Address - City:JACKSON
Practice Address - State:MS
Practice Address - Zip Code:39216-4608
Practice Address - Country:US
Practice Address - Phone:601-200-2780
Practice Address - Fax:601-200-2788
Is Sole Proprietor?:No
Enumeration Date:2016-06-19
Last Update Date:2025-09-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IAR-10660208600000X
MS35449208G00000X
390200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208G00000XAllopathic & Osteopathic PhysiciansThoracic Surgery (Cardiothoracic Vascular Surgery)
No208600000XAllopathic & Osteopathic PhysiciansSurgery
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program