Healthcare Provider Details

I. General information

NPI: 1225006539
Provider Name (Legal Business Name): THEODORE KOERNER III CRNA
Entity Type: Individual
Gender: Male
Sole Proprietor: X

II. Dates (important events)

Enumeration Date: 03/10/2006
Last Update Date: 01/27/2026
Certification Date: 01/27/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

100 FRIST CT # 200
COLUMBUS GA
31909-3578
US

IV. Provider business mailing address

PO BOX 1473
FORTSON GA
31808-1473
US

V. Phone/Fax

Practice location:
  • Phone: 706-494-2100
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code367500000X
TaxonomyCertified Registered Nurse Anesthetist
License NumberARNP2024602
License Number StateFL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: