Provider Demographics
NPI:1245312750
Name:GARDEN VALLEY FAMILY MEDICINE PC
Entity type:Organization
Organization Name:GARDEN VALLEY FAMILY MEDICINE PC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:MICHAEL
Authorized Official - Middle Name:R
Authorized Official - Last Name:KOENIG
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:208-462-3533
Mailing Address - Street 1:PO BOX 270
Mailing Address - Street 2:
Mailing Address - City:GARDEN VALLEY
Mailing Address - State:ID
Mailing Address - Zip Code:83622-0270
Mailing Address - Country:US
Mailing Address - Phone:208-462-3533
Mailing Address - Fax:208-462-3736
Practice Address - Street 1:856 BANKS LOWMAN ROAD
Practice Address - Street 2:
Practice Address - City:GARDEN VALLEY
Practice Address - State:ID
Practice Address - Zip Code:83622
Practice Address - Country:US
Practice Address - Phone:208-462-3533
Practice Address - Fax:208-462-3736
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-10-20
Last Update Date:2018-03-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
ID1368501Medicare ID - Type UnspecifiedCIGNA MEDICARE