MEDICARE: ALBERT SAMUEL KOENIG, III, PA

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	207ZP0105X	Clinical Pathology/Laboratory Medicine Physician	C4336	AR
2	207ZP0101X	Anatomic Pathology Physician	C4336	AR
3	207Q00000X	Family Medicine Physician	C4336	AR

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program
2	5B289	OTHER	AR	ARKANSAS BLUE CROSS & BLU

General Provider Information

NPI Number	:	1992848162
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	ALBERT SAMUEL KOENIG, III, PA

Provider Business Mailing Address
First Line	:	2420 ROGERS AVE
Second Line	:
City	:	FORT SMITH
State	:	AR
Zip	:	72901-4164
Country	:	US
Telephone Number	:	479-782-4000
Fax Number	:	479-782-0265

Provider Business Practice Location Address
First Line	:	2420 ROGERS AVE
Second Line	:
City	:	FORT SMITH
State	:	AR
Zip	:	72901-4164
Country	:	US
Telephone Number	:	479-782-4000
Fax Number	:	479-782-0265

Authorized Official
Title or Position	:	CORPORATION PRESIDENT
Name	:	DR. ALBERT SAMUEL KOENIG III
Credential	:	M.D.
Telephone Number	:	479-782-4000

Provider Enumeration Date	:	02/15/2007
Last Update Date	:	06/19/2008

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