1275973539 NPI number — DR. ROSEMARY TAKYI KOEPPEL M.D.

Table of content: DR. ROSEMARY TAKYI KOEPPEL M.D. (NPI 1275973539)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1275973539 NPI number — DR. ROSEMARY TAKYI KOEPPEL M.D.

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
KOEPPEL
Provider First Name:
ROSEMARY
Provider Middle Name:
TAKYI
Provider Name Prefix Text:
DR.
Provider Name Suffix Text:
Provider Credential Text:
M.D.
Provider Gender Code:
F

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
OWUSU
Provider Other First Name:
ROSEMARY
Provider Other Middle Name:
TAKYI
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
MD
Provider Other Last Name Type Code:
1

NPI Number Information

NPI Number:
1275973539
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
06/13/2016
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
PO BOX 3428
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
SPRINGFIELD
Provider Business Mailing Address State Name:
IL
Provider Business Mailing Address Postal Code:
62708-3428
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
217-243-0300
Provider Business Mailing Address Fax Number:
217-245-6775

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
15 FOUNDERS LN
Provider Second Line Business Practice Location Address:
SUITE 100
Provider Business Practice Location Address City Name:
JACKSONVILLE
Provider Business Practice Location Address State Name:
IL
Provider Business Practice Location Address Postal Code:
62650-3919
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
217-243-0300
Provider Business Practice Location Address Fax Number:
217-245-6775
Provider Enumeration Date:
07/01/2013

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: 208000000X , with the licence number:  036140103 , 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)





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