1174516991 NPI number — MR. ROBERT KOUPAL LCSW

Table of content: MR. ROBERT KOUPAL LCSW (NPI 1174516991)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1174516991 NPI number — MR. ROBERT KOUPAL LCSW

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
KOUPAL
Provider First Name:
ROBERT
Provider Middle Name:
Provider Name Prefix Text:
MR.
Provider Name Suffix Text:
Provider Credential Text:
LCSW
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:
1174516991
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
04/22/2013
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
2102 E 38TH ST
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
DAVENPORT
Provider Business Mailing Address State Name:
IA
Provider Business Mailing Address Postal Code:
52807-1135
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
563-359-4049
Provider Business Mailing Address Fax Number:

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
2102 E 38TH ST
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
DAVENPORT
Provider Business Practice Location Address State Name:
IA
Provider Business Practice Location Address Postal Code:
52807-1135
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
563-359-4049
Provider Business Practice Location Address Fax Number:
563-359-4069
Provider Enumeration Date:
08/26/2005

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: 1041C0700X , with the licence number:  149006072 , registered in the state of IL ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 1041C0700X , with the licence number: 00529 , registered in the state of IA ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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

  • Identifier: 99862 . This is a "BLUE CROSS IOWA IL NUMBER" identifier , issued by the state of ( IL ) . This identifiers is of the category "OTHER".
  • Identifier: 34752 . This is a "BLUE CROSS IOWA IA NUMBER" identifier , issued by the state of ( IA ) . This identifiers is of the category "OTHER".
  • Identifier: 2216745 . This is a "FIRST HEALTH AND CCN NUMB" identifier , issued by the state of ( IL ) . This identifiers is of the category "OTHER".
  • Identifier: 0582221 , issued by the state of ( IL ) . This identifiers is of the category "MEDICAID".
  • Identifier: IL0199 . This is a "JOHN DEERE NUMBER" identifier , issued by the state of ( IL ) . This identifiers is of the category "OTHER".
  • Identifier: 149006072 . This is a "BLUE CROSS ILLINOIS NUMBE" identifier , issued by the state of ( IL ) . This identifiers is of the category "OTHER".
  • Identifier: 1582221 , issued by the state of ( IL ) . This identifiers is of the category "MEDICAID".




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