1679573307 NPI number — ADAM KOPELAN

Table of content: ADAM KOPELAN (NPI 1679573307)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1679573307 NPI number — ADAM KOPELAN

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
KOPELAN
Provider First Name:
ADAM
Provider Middle Name:
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
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:
1679573307
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
04/30/2024
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
225 MILLBURN AVE
Provider Second Line Business Mailing Address:
SUITE 104B
Provider Business Mailing Address City Name:
MILLBURN
Provider Business Mailing Address State Name:
NJ
Provider Business Mailing Address Postal Code:
07041-1737
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
973-379-5888
Provider Business Mailing Address Fax Number:
973-912-9757

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
225 MILLBURN AVE
Provider Second Line Business Practice Location Address:
SUITE 104B
Provider Business Practice Location Address City Name:
MILLBURN
Provider Business Practice Location Address State Name:
NJ
Provider Business Practice Location Address Postal Code:
07041-1737
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
973-379-5888
Provider Business Practice Location Address Fax Number:
973-912-9757
Provider Enumeration Date:
07/22/2005

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: 208600000X , with the licence number:  25MA07605700 , registered in the state of NJ ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 174400000X , with the licence number: 25MA07605700 , registered in the state of NJ ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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

  • Identifier: 7943610 . This is a "AETNA PPO #" identifier , issued by the state of ( NJ ) . This identifiers is of the category "OTHER".
  • Identifier: 3630367 . This is a "AETNA HMO #" identifier , issued by the state of ( NJ ) . This identifiers is of the category "OTHER".
  • Identifier: 0052281 , issued by the state of ( NJ ) . This identifiers is of the category "MEDICAID".
  • Identifier: 8221580 . This is a "GHI PPO #" identifier , issued by the state of ( NJ ) . This identifiers is of the category "OTHER".
  • Identifier: 2K8702 . This is a "HEALTHNET #" identifier , issued by the state of ( NJ ) . This identifiers is of the category "OTHER".
  • Identifier: 2417571000 . This is a "AMERIHEALTH #" identifier , issued by the state of ( NJ ) . This identifiers is of the category "OTHER".
  • Identifier: P00123010 . This is a "RAILROAD MDCR #" identifier , issued by the state of ( NJ ) . This identifiers is of the category "OTHER".




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