Provider Demographics
NPI:1083679070
Name:KOENIG, EARL R (MD)
Entity Type:Individual
Prefix:
First Name:EARL
Middle Name:R
Last Name:KOENIG
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Gender:M
Credentials:MD
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Mailing Address - Street 1:20952 E 12 MILE RD
Mailing Address - Street 2:SUITE 200
Mailing Address - City:ST CLAIR SHORES
Mailing Address - State:MI
Mailing Address - Zip Code:48081-3200
Mailing Address - Country:US
Mailing Address - Phone:586-771-4820
Mailing Address - Fax:586-771-6620
Practice Address - Street 1:11051 HALL RD
Practice Address - Street 2:SUITE 200
Practice Address - City:UTICA
Practice Address - State:MI
Practice Address - Zip Code:48317-5735
Practice Address - Country:US
Practice Address - Phone:586-254-5759
Practice Address - Fax:586-254-5793
Is Sole Proprietor?:No
Enumeration Date:2006-04-20
Last Update Date:2008-07-28
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Provider Licenses
StateLicense IDTaxonomies
MI4301030802208800000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208800000XAllopathic & Osteopathic PhysiciansUrology
Provider Identifiers
StateIdentifier IDID TypeIssuer
MIB45210OtherHAP
MI4391724OtherAETNA
MI5259095001OtherCIGNA
MI102426OtherPRIORITY HEALTH
MI340019484OtherRAILROAD MEDICARE
MI5259095001OtherCIGNA
MIB45210OtherHAP
MI102426OtherPRIORITY HEALTH