Healthcare Provider Details

I. General information

NPI: 1245736990
Provider Name (Legal Business Name): ANDREW KOENIG
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 04/02/2018
Last Update Date: 03/23/2021
Certification Date: 03/23/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

616 N MAIN ST
ROYAL OAK MI
48067-1834
US

IV. Provider business mailing address

5500 AUTO CLUB DR STE 150
DEARBORN MI
48126-2779
US

V. Phone/Fax

Practice location:
  • Phone: 248-648-7170
  • Fax:
Mailing address:
  • Phone: 313-982-8266
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code225100000X
TaxonomyPhysical Therapist
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: