1639481070 NPI number — KERRI LYNN KOPCZUK P.A.

Table of content: KERRI LYNN KOPCZUK P.A. (NPI 1639481070)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1639481070 NPI number — KERRI LYNN KOPCZUK P.A.

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
KOPCZUK
Provider First Name:
KERRI
Provider Middle Name:
LYNN
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
P.A.
Provider Gender Code:
F

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
MICHELLA
Provider Other First Name:
KERRI
Provider Other Middle Name:
LYNN
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:
1

NPI Number Information

NPI Number:
1639481070
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
06/08/2022
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
833 CHESTNUT ST STE 520
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
PHILADELPHIA
Provider Business Mailing Address State Name:
PA
Provider Business Mailing Address Postal Code:
19107-4430
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
609-677-7003
Provider Business Mailing Address Fax Number:
267-339-3761

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
50 CRAIG RD
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
MONTVALE
Provider Business Practice Location Address State Name:
NJ
Provider Business Practice Location Address Postal Code:
07645-1709
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
888-636-7840
Provider Business Practice Location Address Fax Number:
267-479-1321
Provider Enumeration Date:
07/13/2010

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: 363A00000X , with the licence number:  014031 , registered in the state of NY ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 363AS0400X , with the licence number: 014031 , registered in the state of NY ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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

  • Identifier: 03280100 , issued by the state of ( NY ) . This identifiers is of the category "MEDICAID".