1104165091 NPI number — CAPITAL ARTHROSCOPY SPORTS MEDICINE TRAUMA SURGERY PA

Table of content: JESSICA RAE KOPMEYER LMSW (NPI 1417601824)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1104165091 NPI number — CAPITAL ARTHROSCOPY SPORTS MEDICINE TRAUMA SURGERY PA

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
CAPITAL ARTHROSCOPY SPORTS MEDICINE TRAUMA SURGERY PA
Provider Last Name:
Provider First Name:
Provider Middle Name:
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
Provider Gender Code:

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:
1104165091
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
04/18/2013
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
PO BOX 302405
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
AUSTIN
Provider Business Mailing Address State Name:
TX
Provider Business Mailing Address Postal Code:
78703-0041
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
512-720-8215
Provider Business Mailing Address Fax Number:
281-254-7864

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
4112 LINKS LN
Provider Second Line Business Practice Location Address:
SUITE 101
Provider Business Practice Location Address City Name:
ROUND ROCK
Provider Business Practice Location Address State Name:
TX
Provider Business Practice Location Address Postal Code:
78664-3901
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
512-720-8215
Provider Business Practice Location Address Fax Number:
281-254-7864
Provider Enumeration Date:
02/12/2013

Additional Information

Authorized Official

Authorized Official Last Name:
DUGGAN
Authorized Official First Name:
JOHN
Authorized Official Middle Name:
PATRICK
Authorized Official Title or Position:
ORTHOPEDIC SURGEON
Authorized Official Telephone Number:
512-364-6562

Provider Taxonomy Codes

  • Taxonomy code: 207X00000X , with the licence number:  M9262 , registered in the state of TX ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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





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