Healthcare Provider Details

I. General information

NPI: 1053236497
Provider Name (Legal Business Name): BRYAN KOENIG
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 08/13/2026
Last Update Date: 08/13/2026
Certification Date: 08/04/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

24 E MAIN ST
NORWICH NY
13815-1810
US

IV. Provider business mailing address

131 COUNTY RD 23
NORWICH NY
13815
US

V. Phone/Fax

Practice location:
  • Phone: 607-287-8518
  • Fax:
Mailing address:
  • Phone: 607-287-8518
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code175T00000X
TaxonomyPeer Specialist
License NumberCRPA-7063
License Number StateNY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: