Healthcare Provider Details

I. General information

NPI: 1619930559
Provider Name (Legal Business Name): MARIANNE SARAH KOENIG M.D.
Entity Type: Individual
Gender: Female
Sole Proprietor: X

II. Dates (important events)

Enumeration Date: 04/11/2006
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

449 ROUTE 130
SANDWICH MA
02563-2339
US

IV. Provider business mailing address

449 ROUTE 130
SANDWICH MA
02563-2339
US

V. Phone/Fax

Practice location:
  • Phone: 508-888-8430
  • Fax: 508-888-6673
Mailing address:
  • Phone: 508-888-8430
  • Fax: 508-888-6673

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code2080A0000X
TaxonomyPediatric Adolescent Medicine Physician
License Number50001
License Number StateMA

VII. Legacy identifiers

For crosswalk purposes, the following legacy (non-NPI) identifiers are available for this provider:

# 1
Identifier28345
Identifier TypeOTHER
Identifier StateMA
Identifier IssuerCHILDRENS MEDICAL SECURIT
# 2
IdentifierS011190
Identifier TypeOTHER
Identifier StateMA
Identifier IssuerTRICARE
# 3
Identifier20140
Identifier TypeOTHER
Identifier StateMA
Identifier IssuerHARVARD PILGRIM HEALTH CA
# 4
IdentifierKOJO4544
Identifier TypeOTHER
Identifier StateMA
Identifier IssuerBLUE CROSS BLUE SHIELD
# 5
Identifier1200958
Identifier TypeOTHER
Identifier StateMA
Identifier IssuerUNITED HEALTHCARE
# 6
Identifier3000532
Identifier TypeMEDICAID
Identifier StateMA
Identifier Issuer
# 7
Identifier4849274
Identifier TypeOTHER
Identifier StateMA
Identifier IssuerCIGNA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: