Provider Demographics
NPI:1659751915
Name:KOONCE SURGICAL PC
Entity Type:Organization
Organization Name:KOONCE SURGICAL PC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PHYSICIAN
Authorized Official - Prefix:DR
Authorized Official - First Name:CASSIDY
Authorized Official - Middle Name:J
Authorized Official - Last Name:KOONCE
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:256-216-6500
Mailing Address - Street 1:201 N MALONE ST
Mailing Address - Street 2:
Mailing Address - City:ATHENS
Mailing Address - State:AL
Mailing Address - Zip Code:35611-1509
Mailing Address - Country:US
Mailing Address - Phone:256-216-6500
Mailing Address - Fax:256-216-8777
Practice Address - Street 1:201 N MALONE ST
Practice Address - Street 2:
Practice Address - City:ATHENS
Practice Address - State:AL
Practice Address - Zip Code:35611-1509
Practice Address - Country:US
Practice Address - Phone:256-216-6500
Practice Address - Fax:256-216-8777
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2015-06-02
Last Update Date:2015-06-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ALMD31380174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes174400000XOther Service ProvidersSpecialistGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
AL1376854976OtherNPI