Basic Information
| Provider Information | |||||||||
| NPI: | 1316393879 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | COPPERWHEAT | ||||||||
| FirstName: | KENNETH | ||||||||
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| Credential: | DO | ||||||||
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| Mailing Information | |||||||||
| Address1: | 5100 W 110TH ST STE 110 | ||||||||
| Address2: | |||||||||
| City: | OVERLAND PARK | ||||||||
| State: | KS | ||||||||
| PostalCode: | 662111215 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9133456960 | ||||||||
| FaxNumber: | 9133456966 | ||||||||
| Practice Location | |||||||||
| Address1: | 2737 WARM SPRINGS RD STE A | ||||||||
| Address2: | |||||||||
| City: | COLUMBUS | ||||||||
| State: | GA | ||||||||
| PostalCode: | 319045328 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7066602950 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 05/13/2016 | ||||||||
| LastUpdateDate: | 09/27/2022 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | Y | ||||||||
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| NPICertificationDate: | 09/27/2022 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 208600000X | 05-43987 | KS | N | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Surgery | 390200000X | N | Student, Health Care | Student in an Organized Health Care Education/Training Program | 208600000X | 92781 | GA | Y | Allopathic & Osteopathic Physicians | Surgery |
No ID Information.