Basic Information
| Provider Information | |||||||||
| NPI: | 1124007125 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | COPPOLA | ||||||||
| FirstName: | GREGORY | ||||||||
| MiddleName: | W | ||||||||
| NamePrefix: | DR. | ||||||||
| NameSuffix: | |||||||||
| Credential: | DO | ||||||||
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| Mailing Information | |||||||||
| Address1: | 1 LECOM PL | ||||||||
| Address2: | |||||||||
| City: | ERIE | ||||||||
| State: | PA | ||||||||
| PostalCode: | 165052571 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | |||||||||
| FaxNumber: | 8148682522 | ||||||||
| Practice Location | |||||||||
| Address1: | 5215 PEACH ST | ||||||||
| Address2: | |||||||||
| City: | ERIE | ||||||||
| State: | PA | ||||||||
| PostalCode: | 165092419 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8148668610 | ||||||||
| FaxNumber: | 8148668614 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 01/10/2006 | ||||||||
| LastUpdateDate: | 01/04/2017 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 204D00000X | OS010713L | PA | Y | Allopathic & Osteopathic Physicians | Neuromusculoskeletal Medicine & OMM | 207QS0010X | OS010713L | PA | N | Allopathic & Osteopathic Physicians | Family Medicine | Sports Medicine |
ID Information
| ID | Type | State | Issuer | Description | 0018041330009 | 05 | PA | MEDICAID | 0018041330011 | 05 | PA | MEDICAID |