Provider Demographics
NPI:1720067804
Name:SKOCH, MARY KATHLEEN (MD)
Entity type:Individual
Prefix:DR
First Name:MARY
Middle Name:KATHLEEN
Last Name:SKOCH
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 1:20826 MOREWOOD PKWY
Mailing Address - Street 2:
Mailing Address - City:ROCKY RIVER
Mailing Address - State:OH
Mailing Address - Zip Code:44116-1447
Mailing Address - Country:US
Mailing Address - Phone:440-333-0653
Mailing Address - Fax:
Practice Address - Street 1:14701 DETROIT AVE
Practice Address - Street 2:SUITE 250
Practice Address - City:LAKEWOOD
Practice Address - State:OH
Practice Address - Zip Code:44107-4115
Practice Address - Country:US
Practice Address - Phone:216-221-5901
Practice Address - Fax:216-221-5881
Is Sole Proprietor?:No
Enumeration Date:2006-01-17
Last Update Date:2011-12-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH35057882208000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208000000XAllopathic & Osteopathic PhysiciansPediatrics
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH0794074Medicaid
OH7260511Medicare ID - Type Unspecified
OH0794074Medicaid