Healthcare Provider Details

I. General information

NPI: 1992848162
Provider Name (Legal Business Name): ALBERT SAMUEL KOENIG, III, PA
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 02/15/2007
Last Update Date: 06/19/2008
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2420 ROGERS AVE
FORT SMITH AR
72901-4164
US

IV. Provider business mailing address

2420 ROGERS AVE
FORT SMITH AR
72901-4164
US

V. Phone/Fax

Practice location:
  • Phone: 479-782-4000
  • Fax: 479-782-0265
Mailing address:
  • Phone: 479-782-4000
  • Fax: 479-782-0265

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code207ZP0105X
TaxonomyClinical Pathology/Laboratory Medicine Physician
License NumberC4336
License Number StateAR
# 2
Primary TaxonomyN
Taxonomy Code207ZP0101X
TaxonomyAnatomic Pathology Physician
License NumberC4336
License Number StateAR
# 3
Primary TaxonomyY
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License NumberC4336
License Number StateAR

VIII. Authorized Official

Name: DR. ALBERT SAMUEL KOENIG III
Title or Position: CORPORATION PRESIDENT
Credential: M.D.
Phone: 479-782-4000