Provider Demographics
NPI:1295986412
Name:C. SCOTT KOENIG
Entity type:Organization
Organization Name:C. SCOTT KOENIG
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PHYSICIAN
Authorized Official - Prefix:DR
Authorized Official - First Name:COREY
Authorized Official - Middle Name:SCOTT
Authorized Official - Last Name:KOENIG
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:508-764-3200
Mailing Address - Street 1:79 SAYLES ST
Mailing Address - Street 2:
Mailing Address - City:SOUTHBRIDGE
Mailing Address - State:MA
Mailing Address - Zip Code:01550-1729
Mailing Address - Country:US
Mailing Address - Phone:508-764-3200
Mailing Address - Fax:508-764-9600
Practice Address - Street 1:79 SAYLES ST
Practice Address - Street 2:
Practice Address - City:SOUTHBRIDGE
Practice Address - State:MA
Practice Address - Zip Code:01550-1729
Practice Address - Country:US
Practice Address - Phone:508-764-3200
Practice Address - Fax:508-764-9600
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-10-07
Last Update Date:2010-04-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MA72556207VG0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207VG0400XAllopathic & Osteopathic PhysiciansObstetrics & GynecologyGynecologyGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
MA3066100Medicaid
MA3066100Medicaid
E57735Medicare UPIN