Provider Demographics
NPI:1013919489
Name:KOELSCH, DAVID WERNER (MD)
Entity Type:Individual
Prefix:DR
First Name:DAVID
Middle Name:WERNER
Last Name:KOELSCH
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:120 ADMINISTRATION RD
Mailing Address - Street 2:
Mailing Address - City:OAK RIDGE
Mailing Address - State:TN
Mailing Address - Zip Code:37830-8822
Mailing Address - Country:US
Mailing Address - Phone:865-483-7030
Mailing Address - Fax:865-483-3954
Practice Address - Street 1:120 ADMINISTRATION RD
Practice Address - Street 2:
Practice Address - City:OAK RIDGE
Practice Address - State:TN
Practice Address - Zip Code:37830-8822
Practice Address - Country:US
Practice Address - Phone:865-483-7030
Practice Address - Fax:865-483-3954
Is Sole Proprietor?:No
Enumeration Date:2005-08-15
Last Update Date:2022-05-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TN47206208600000X
KY36460208600000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208600000XAllopathic & Osteopathic PhysiciansSurgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
KY000000191916OtherBC/BS PIN #
TNQ073499Medicaid
KY65933855Medicaid
KY611330797001OtherTRICARE GRP #
KY64030935Medicaid
KY9127537002OtherCIGNA PIN #
KYCB3611OtherRR MEDICARE GRP #
TN4012852OtherTN BC/BS PIN #
KYCB3611OtherRR MEDICARE GRP #
KY1801902341OtherGROUP NPI
TN4012852OtherTN BC/BS PIN #