1477746873 NPI number — EWA KOPEC M.S., P.T.

Table of content: MR. GARY M JONES DPH (NPI 1477693026)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1477746873 NPI number — EWA KOPEC M.S., P.T.

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
KOPEC
Provider First Name:
EWA
Provider Middle Name:
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
M.S., P.T.
Provider Gender Code:
F

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:
1477746873
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
07/22/2008
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
3545 LAKE AVE
Provider Second Line Business Mailing Address:
SUITE 103
Provider Business Mailing Address City Name:
WILMETTE
Provider Business Mailing Address State Name:
IL
Provider Business Mailing Address Postal Code:
60091-1058
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
847-251-2028
Provider Business Mailing Address Fax Number:
847-512-5064

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
3545 LAKE AVE
Provider Second Line Business Practice Location Address:
SUITE 103
Provider Business Practice Location Address City Name:
WILMETTE
Provider Business Practice Location Address State Name:
IL
Provider Business Practice Location Address Postal Code:
60091-1058
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
847-251-2028
Provider Business Practice Location Address Fax Number:
847-512-5064
Provider Enumeration Date:
08/20/2007

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: 225100000X , with the licence number:  70015237 , registered in the state of IL ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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

  • Identifier: 01634372 . This is a "BCI BCBS GROUP NO." identifier , issued by the state of ( IL ) . This identifiers is of the category "OTHER".
  • Identifier: 363396874 . This is a "PEAK TAX ID" identifier , issued by the state of ( IL ) . This identifiers is of the category "OTHER".
  • Identifier: 1618443 . This is a "PEAK BCBS GROUP NO." identifier , issued by the state of ( IL ) . This identifiers is of the category "OTHER".
  • Identifier: 236963283001 , issued by the state of ( IL ) . This identifiers is of the category "MEDICAID".
  • Identifier: 200573902 . This is a "BCI TAX ID" identifier , issued by the state of ( IL ) . This identifiers is of the category "OTHER".




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