Provider Demographics
NPI:1619683760
Name:KOEHN, MADISON
Entity Type:Individual
Prefix:
First Name:MADISON
Middle Name:
Last Name:KOEHN
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2809 ELDORADO PL
Mailing Address - Street 2:
Mailing Address - City:GARDEN CITY
Mailing Address - State:KS
Mailing Address - Zip Code:67846-7320
Mailing Address - Country:US
Mailing Address - Phone:620-640-6833
Mailing Address - Fax:
Practice Address - Street 1:506 N THORPE ST
Practice Address - Street 2:
Practice Address - City:LAKIN
Practice Address - State:KS
Practice Address - Zip Code:67860
Practice Address - Country:US
Practice Address - Phone:620-355-7550
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2023-01-23
Last Update Date:2023-01-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes175T00000XOther Service ProvidersPeer Specialist
Provider Identifiers
StateIdentifier IDID TypeIssuer
KSKRM100010263721OtherBLUE CROSS & BLUE SHIELD