Basic Information
| Provider Information | |||||||||
| NPI: | 1689678914 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | KOENIG | ||||||||
| FirstName: | THOMAS | ||||||||
| MiddleName: | A | ||||||||
| NamePrefix: | |||||||||
| NameSuffix: | |||||||||
| Credential: | SAC | ||||||||
| OtherOrganizationName: | |||||||||
| OtherOrganizationType: | |||||||||
| OtherLastName: | KOENIG | ||||||||
| OtherFirstName: | THOMAS | ||||||||
| OtherMiddleName: | A | ||||||||
| OtherNamePrefix: | |||||||||
| OtherNameSuffix: | |||||||||
| OtherCredential: | OPA-C | ||||||||
| OtherLastNameType: | 5 | ||||||||
| Mailing Information | |||||||||
| Address1: | 560 SOUTH LOOP RD | ||||||||
| Address2: | |||||||||
| City: | EDGEWOOD | ||||||||
| State: | KY | ||||||||
| PostalCode: | 410173454 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8593012663 | ||||||||
| FaxNumber: | 8593010655 | ||||||||
| Practice Location | |||||||||
| Address1: | 560 SOUTH LOOP RD | ||||||||
| Address2: | |||||||||
| City: | EDGEWOOD | ||||||||
| State: | KY | ||||||||
| PostalCode: | 410173454 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8593012663 | ||||||||
| FaxNumber: | 8593010655 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 06/01/2005 | ||||||||
| LastUpdateDate: | 03/06/2008 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | |||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 363AS0400X | 02-296 | KY | Y | Physician Assistants & Advanced Practice Nursing Providers | Physician Assistant | Surgical |
ID Information
| ID | Type | State | Issuer | Description | CSA98601 | 01 | KY | CHOICE CARE PROVIDER ID | OTHER |