=====================================================
General NPI Number Information
=====================================================
NPI Number | 1659751915
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | KOONCE SURGICAL PC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 06/02/2015
-----------------------------------------------------
Last Update Date | 03/21/2025
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 707 W MARKET ST STE C
-----------------------------------------------------
City | ATHENS
-----------------------------------------------------
State | AL
-----------------------------------------------------
Zip | 35611-2463
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 256-216-6500
-----------------------------------------------------
Fax | 256-216-8777
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | PO BOX 630
-----------------------------------------------------
City | ATHENS
-----------------------------------------------------
State | AL
-----------------------------------------------------
Zip | 35612-0630
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 256-216-6500
-----------------------------------------------------
Fax | 256-216-8777
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | PHYSICIAN
-----------------------------------------------------
Name | DR. CASSIDY J KOONCE
-----------------------------------------------------
Credential | MD
-----------------------------------------------------
Telephone | 256-216-6500
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 174400000X
-----------------------------------------------------
Taxonomy Name | Specialist
-----------------------------------------------------
License Number | MD31380
-----------------------------------------------------
License Number State | AL
-----------------------------------------------------