1437126141 NPI number — NEDRA S KOENIG M.A.

Table of content: NEDRA S KOENIG M.A. (NPI 1437126141)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1437126141 NPI number — NEDRA S KOENIG M.A.

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
KOENIG
Provider First Name:
NEDRA
Provider Middle Name:
S
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
M.A.
Provider Gender Code:
F

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
KAVICKY
Provider Other First Name:
NEDRA
Provider Other Middle Name:
S
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
M.A.
Provider Other Last Name Type Code:
1

NPI Number Information

NPI Number:
1437126141
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
10/13/2009
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
1 E. MERCHANTS DRIVE
Provider Second Line Business Mailing Address:
SUITE 303
Provider Business Mailing Address City Name:
OSWEGO
Provider Business Mailing Address State Name:
IL
Provider Business Mailing Address Postal Code:
60543
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
630-897-7492
Provider Business Mailing Address Fax Number:
630-588-0502

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
1 E. MERCHANTS DRIVE
Provider Second Line Business Practice Location Address:
SUITE 303
Provider Business Practice Location Address City Name:
OSWEGO
Provider Business Practice Location Address State Name:
IL
Provider Business Practice Location Address Postal Code:
60543
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
630-897-7492
Provider Business Practice Location Address Fax Number:
630-588-0502
Provider Enumeration Date:
03/01/2006

Additional Information

Authorized Official

Authorized Official Last Name:
Authorized Official First Name:
Authorized Official Middle Name:
Authorized Official Title or Position:
Authorized Official Telephone Number:

Provider Taxonomy Codes

  • Taxonomy code: 106H00000X , with the licence number:  166-000402 , registered in the state of IL ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)

  • Identifier: 02232135 . This is a "BLUE CROSS & BLUE SHIELD" identifier , issued by the state of ( IL ) . This identifiers is of the category "OTHER".
  • Identifier: 1033869 . This is a "CIGNA PROVIDER" identifier , issued by the state of ( IL ) . This identifiers is of the category "OTHER".
  • Identifier: 780513 . This is a "HOLMAN GROUP" identifier , issued by the state of ( IL ) . This identifiers is of the category "OTHER".
  • Identifier: 5401280 . This is a "AETNA" identifier . This identifiers is of the category "OTHER".
  • Identifier: 101621301 . This is a "UBH" identifier , issued by the state of ( IL ) . This identifiers is of the category "OTHER".
  • Identifier: 239972000 . This is a "MAGELLAN PROVIDER" identifier , issued by the state of ( IL ) . This identifiers is of the category "OTHER".
  • Identifier: 408124 . This is a "VALUEOPTIONS" identifier , issued by the state of ( IL ) . This identifiers is of the category "OTHER".




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