1578562062 NPI number — JOSEPH LEE KOEN M.D.

Table of content: JOSEPH LEE KOEN M.D. (NPI 1578562062)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1578562062 NPI number — JOSEPH LEE KOEN M.D.

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
KOEN
Provider First Name:
JOSEPH
Provider Middle Name:
LEE
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
M.D.
Provider Gender Code:
M

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1578562062
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
02/04/2022
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
300 MEDICAL PKWY STE 200
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
CHESAPEAKE
Provider Business Mailing Address State Name:
VA
Provider Business Mailing Address Postal Code:
23320-4985
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
757-625-4455
Provider Business Mailing Address Fax Number:
757-625-1829

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
300 MEDICAL PKWY STE 200
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
CHESAPEAKE
Provider Business Practice Location Address State Name:
VA
Provider Business Practice Location Address Postal Code:
23320-4985
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
757-625-4455
Provider Business Practice Location Address Fax Number:
757-625-1829
Provider Enumeration Date:
07/18/2005

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: 207T00000X , with the licence number:  0101221499 , registered in the state of VA ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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

  • Identifier: 20186 . This is a "SENTARA HEALTH PLAN" identifier . This identifiers is of the category "OTHER".
  • Identifier: 271748 . This is a "MDIPA/MAMSI" identifier . This identifiers is of the category "OTHER".
  • Identifier: 590581A . This is a "MEDICAID OF NC" identifier , issued by the state of ( NC ) . This identifiers is of the category "OTHER".
  • Identifier: 140006635 . This is a "RAILROAD MEDICARE" identifier , issued by the state of ( VA ) . This identifiers is of the category "OTHER".
  • Identifier: 284493 . This is a "ANTHEM BCBS" identifier , issued by the state of ( VA ) . This identifiers is of the category "OTHER".
  • Identifier: 5479722 . This is a "ANTHEM HEALTH PLAN" identifier . This identifiers is of the category "OTHER".
  • Identifier: 590581A . This is a "BCBS OF NC" identifier , issued by the state of ( NC ) . This identifiers is of the category "OTHER".
  • Identifier: 006105611 , issued by the state of ( VA ) . This identifiers is of the category "MEDICAID".
  • Identifier: 149158900 . This is a "US DEPT OF LABOR" identifier . This identifiers is of the category "OTHER".




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