1578557195 NPI number — EILZABETH CONVERY COPPOLA BS, MS

Table of content: EILZABETH CONVERY COPPOLA BS, MS (NPI 1578557195)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1578557195 NPI number — EILZABETH CONVERY COPPOLA BS, MS

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
COPPOLA
Provider First Name:
EILZABETH
Provider Middle Name:
CONVERY
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
BS, MS
Provider Gender Code:
F

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
CROSBY
Provider Other First Name:
EILZABETH
Provider Other Middle Name:
C
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:
1578557195
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
09/24/2009
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
PO BOX 249
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
LONGVIEW
Provider Business Mailing Address State Name:
WA
Provider Business Mailing Address Postal Code:
98632-7154
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
360-414-2048
Provider Business Mailing Address Fax Number:
360-575-6749

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
600 BROADWAY ST
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
LONGVIEW
Provider Business Practice Location Address State Name:
WA
Provider Business Practice Location Address Postal Code:
98632-3256
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
360-636-4943
Provider Business Practice Location Address Fax Number:
360-414-7674
Provider Enumeration Date:
09/09/2005

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: 133V00000X , with the licence number:  DI00001498 , registered in the state of WA ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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

  • Identifier: 100431 , issued by the state of ( OR ) . This identifiers is of the category "MEDICAID".
  • Identifier: 8331332 , issued by the state of ( WA ) . This identifiers is of the category "MEDICAID".




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