1518983964 NPI number — HAROLD P KOPITZKI DO

Table of content: HAROLD P KOPITZKI DO (NPI 1518983964)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1518983964 NPI number — HAROLD P KOPITZKI DO

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
KOPITZKI
Provider First Name:
HAROLD
Provider Middle Name:
P
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
DO
Provider Gender Code:
M

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1518983964
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
07/09/2007
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
24423 KENSINGTON
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
FARMINGTON HILLS
Provider Business Mailing Address State Name:
MI
Provider Business Mailing Address Postal Code:
48335-2188
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
810-442-0386
Provider Business Mailing Address Fax Number:

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
30901 PALMER RD
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
WESTLAND
Provider Business Practice Location Address State Name:
MI
Provider Business Practice Location Address Postal Code:
48186-9529
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
734-367-8403
Provider Business Practice Location Address Fax Number:
734-722-9524
Provider Enumeration Date:
07/15/2006

Additional Information

Authorized Official

Authorized Official Last Name:
Authorized Official First Name:
Authorized Official Middle Name:
Authorized Official Title or Position:
Authorized Official Telephone Number:

Provider Taxonomy Codes

  • Taxonomy code: 207Q00000X , with the licence number:  5101007269 , registered in the state of MI ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)

  • Identifier: 010Q26258 . This is a "BCBSM GR#" identifier , issued by the state of ( MI ) . This identifiers is of the category "OTHER".
  • Identifier: HK007269 . This is a "LICENSE" identifier , issued by the state of ( MI ) . This identifiers is of the category "OTHER".
  • Identifier: 1508883299 . This is a "WRPH" identifier , issued by the state of ( MI ) . This identifiers is of the category "OTHER".
  • Identifier: 4867164 , issued by the state of ( MI ) . This identifiers is of the category "MEDICAID".




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