Basic Information
| Provider Information | |||||||||
| NPI: | 1841422672 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | KOPKA | ||||||||
| FirstName: | JERAME | ||||||||
| MiddleName: | JOSEPH | ||||||||
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| Mailing Information | |||||||||
| Address1: | 4212 CONCORD ST | ||||||||
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| City: | MIDLAND | ||||||||
| State: | MI | ||||||||
| PostalCode: | 486423517 | ||||||||
| CountryCode: | US | ||||||||
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| Practice Location | |||||||||
| Address1: | 449 QUARTER ST | ||||||||
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| City: | GLADWIN | ||||||||
| State: | MI | ||||||||
| PostalCode: | 486241918 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9892466302 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 08/12/2009 | ||||||||
| LastUpdateDate: | 08/12/2009 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | Y | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 225X00000X | 5201007115 | MI | Y | Respiratory, Developmental, Rehabilitative and Restorative Service Providers | Occupational Therapist |
No ID Information.