1962599530 NPI number — DR. O'NEAL WILSON KOGER JR. M.D.

Table of content: DR. O'NEAL WILSON KOGER JR. M.D. (NPI 1962599530)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1962599530 NPI number — DR. O'NEAL WILSON KOGER JR. M.D.

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
KOGER
Provider First Name:
O'NEAL
Provider Middle Name:
WILSON
Provider Name Prefix Text:
DR.
Provider Name Suffix Text:
JR.
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:
1962599530
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
04/23/2014
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
30301 WOODWARD AVE
Provider Second Line Business Mailing Address:
120
Provider Business Mailing Address City Name:
ROYAL OAK
Provider Business Mailing Address State Name:
MI
Provider Business Mailing Address Postal Code:
48302
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
248-435-6622
Provider Business Mailing Address Fax Number:
248-435-7453

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
30301 WOODWARD AVE
Provider Second Line Business Practice Location Address:
120
Provider Business Practice Location Address City Name:
ROYAL OAK
Provider Business Practice Location Address State Name:
MI
Provider Business Practice Location Address Postal Code:
48302
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
248-435-6622
Provider Business Practice Location Address Fax Number:
248-435-7453
Provider Enumeration Date:
10/06/2006

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: 207N00000X , with the licence number:  4301053536 , registered in the state of MI ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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

  • Identifier: P67011 . This is a "OLD BCN" identifier , issued by the state of ( MI ) . This identifiers is of the category "OTHER".
  • Identifier: 0706328251 . This is a "INDIV B" identifier , issued by the state of ( MI ) . This identifiers is of the category "OTHER".
  • Identifier: 3361759 , issued by the state of ( MI ) . This identifiers is of the category "MEDICAID".
  • Identifier: 070012496 . This is a "RAILROAD MEDICARE" identifier , issued by the state of ( MI ) . This identifiers is of the category "OTHER".
  • Identifier: 632825 . This is a "NEW BCN" identifier , issued by the state of ( MI ) . This identifiers is of the category "OTHER".
  • Identifier: 9679933 . This is a "CIGNA" identifier , issued by the state of ( MI ) . This identifiers is of the category "OTHER".
  • Identifier: S38359 . This is a "HAP" identifier , issued by the state of ( MI ) . This identifiers is of the category "OTHER".
  • Identifier: 4113337 . This is a "AETNA" identifier , issued by the state of ( MI ) . This identifiers is of the category "OTHER".
  • Identifier: 070F37332 . This is a "BCBS" identifier , issued by the state of ( MI ) . This identifiers is of the category "OTHER".




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