Basic Information
| Provider Information | |||||||||
| NPI: | 1770521502 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | KOENIG | ||||||||
| FirstName: | MARK | ||||||||
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| Credential: | M.D. | ||||||||
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| Mailing Information | |||||||||
| Address1: | 300 20TH AVE N STE 403 | ||||||||
| Address2: | |||||||||
| City: | NASHVILLE | ||||||||
| State: | TN | ||||||||
| PostalCode: | 372035180 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6152847260 | ||||||||
| FaxNumber: | 6152847501 | ||||||||
| Practice Location | |||||||||
| Address1: | 4230 HARDING RD | ||||||||
| Address2: | SUITE 330 | ||||||||
| City: | NASHVILLE | ||||||||
| State: | TN | ||||||||
| PostalCode: | 37205 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6152594545 | ||||||||
| FaxNumber: | 6155656789 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 06/03/2006 | ||||||||
| LastUpdateDate: | 08/02/2021 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 08/02/2021 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207RI0011X | 32261 | TN | Y | Allopathic & Osteopathic Physicians | Internal Medicine | Interventional Cardiology | 207RC0000X | 32261 | TN | N | Allopathic & Osteopathic Physicians | Internal Medicine | Cardiovascular Disease |
ID Information
| ID | Type | State | Issuer | Description | P01376525 | 01 | TN | RR MEDICARE | OTHER | 6012068 | 01 | TN | BLUE CROSS-BLUE SHIELD | OTHER | 3330967 | 05 | TN | MEDICAID |