1124007125 NPI number — DR. GREGORY W COPPOLA DO

Table of content: DR. GREGORY W COPPOLA DO (NPI 1124007125)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1124007125 NPI number — DR. GREGORY W COPPOLA DO

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
COPPOLA
Provider First Name:
GREGORY
Provider Middle Name:
W
Provider Name Prefix Text:
DR.
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:
1124007125
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
01/04/2017
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
1 LECOM PL
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
ERIE
Provider Business Mailing Address State Name:
PA
Provider Business Mailing Address Postal Code:
16505-2571
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
Provider Business Mailing Address Fax Number:
814-868-2522

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
5215 PEACH ST
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
ERIE
Provider Business Practice Location Address State Name:
PA
Provider Business Practice Location Address Postal Code:
16509-2419
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
814-866-8610
Provider Business Practice Location Address Fax Number:
814-866-8614
Provider Enumeration Date:
01/10/2006

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: 204D00000X , with the licence number:  OS010713L , registered in the state of PA ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .
  • Taxonomy code: 207QS0010X , with the licence number: OS010713L , registered in the state of PA ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .

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

  • Identifier: 0018041330009 , issued by the state of ( PA ) . This identifiers is of the category "MEDICAID".
  • Identifier: 0018041330011 , issued by the state of ( PA ) . This identifiers is of the category "MEDICAID".




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