Healthcare Provider Details

I. General information

NPI: 1801906425
Provider Name (Legal Business Name): PETER C KOENIGES M. ED., ATC, CSCS
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 08/30/2006
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

298 HILLSIDE AVE
ALLENDALE NJ
07401-1447
US

IV. Provider business mailing address

513 RIVERVALE RD
RIVER VALE NJ
07675-6468
US

V. Phone/Fax

Practice location:
  • Phone: 201-327-8700
  • Fax:
Mailing address:
  • Phone: 201-970-4470
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code2255A2300X
TaxonomyAthletic Trainer
License NumberMT805
License Number StateNJ

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: