Provider Demographics
NPI:1972798049
Name:KOTH, KEVIN G (DO)
Entity type:Individual
Prefix:
First Name:KEVIN
Middle Name:G
Last Name:KOTH
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:PO BOX 160
Mailing Address - Street 2:
Mailing Address - City:TROY
Mailing Address - State:IL
Mailing Address - Zip Code:62294-0160
Mailing Address - Country:US
Mailing Address - Phone:618-900-1070
Mailing Address - Fax:833-992-2437
Practice Address - Street 1:12866 TROXLER AVE
Practice Address - Street 2:
Practice Address - City:HIGHLAND
Practice Address - State:IL
Practice Address - Zip Code:62249-2806
Practice Address - Country:US
Practice Address - Phone:618-900-1070
Practice Address - Fax:833-992-2437
Is Sole Proprietor?:Yes
Enumeration Date:2007-09-11
Last Update Date:2024-03-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KY03476207X00000X, 207XS0117X
IN02003992A207X00000X
IL036132543207X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207X00000XAllopathic & Osteopathic PhysiciansOrthopaedic Surgery
No207XS0117XAllopathic & Osteopathic PhysiciansOrthopaedic SurgeryOrthopaedic Surgery of the Spine
Provider Identifiers
StateIdentifier IDID TypeIssuer
IN201114320AMedicaid
IL036-132543Medicaid
KY000000777934OtherANTHEM
KY7100213750Medicaid
KY7100213750Medicaid
IN208550004Medicare PIN
IL591820013Medicare PIN