Provider Demographics
NPI:1699767186
Name:BOCH, PHILLIP A (DO)
Entity type:Individual
Prefix:DR
First Name:PHILLIP
Middle Name:A
Last Name:BOCH
Suffix:
Gender:M
Credentials:DO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:6320 CERMAK RD
Mailing Address - Street 2:
Mailing Address - City:BERWYN
Mailing Address - State:IL
Mailing Address - Zip Code:60402-2812
Mailing Address - Country:US
Mailing Address - Phone:708-749-3777
Mailing Address - Fax:
Practice Address - Street 1:6320 CERMAK RD
Practice Address - Street 2:
Practice Address - City:BERWYN
Practice Address - State:IL
Practice Address - Zip Code:60402-2812
Practice Address - Country:US
Practice Address - Phone:708-749-3777
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2005-08-19
Last Update Date:2010-12-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL036-054799207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL363033456OtherFEDERAL TAX ID
IL9530608003OtherCIGNA
IL4656516OtherAETNA
IL120001237OtherRAILROAD MEDICARE
IL21607418OtherBLUE CROSS BLUE SHIELD ID
IL120001237OtherRAILROAD MEDICARE
IL9530608003OtherCIGNA