Basic Information
| Provider Information | |||||||||
| NPI: | 1952332918 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | KOPJAS | ||||||||
| FirstName: | TIBOR | ||||||||
| MiddleName: | CHARLES | ||||||||
| NamePrefix: | DR. | ||||||||
| NameSuffix: | |||||||||
| Credential: | M.D. | ||||||||
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| Mailing Information | |||||||||
| Address1: | 6810 STATE ROUTE 162 BOX 215 | ||||||||
| Address2: | |||||||||
| City: | MARYVILLE | ||||||||
| State: | IL | ||||||||
| PostalCode: | 620628501 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6183916405 | ||||||||
| FaxNumber: | 6182884088 | ||||||||
| Practice Location | |||||||||
| Address1: | 2118 VADALABENE DR | ||||||||
| Address2: | |||||||||
| City: | MARYVILLE | ||||||||
| State: | IL | ||||||||
| PostalCode: | 620625632 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6182887081 | ||||||||
| FaxNumber: | 6182886857 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 07/06/2006 | ||||||||
| LastUpdateDate: | 03/23/2020 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 03/23/2020 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207R00000X | 036070084 | IL | Y | Allopathic & Osteopathic Physicians | Internal Medicine |
ID Information
| ID | Type | State | Issuer | Description | 036070084 | 05 | IL | MEDICAID | 06000515 | 01 | IL | BLUE CROSS | OTHER | 166459 | 01 | IL | GHP | OTHER | 100767 | 01 | IL | HEALTHLINK | OTHER | 110016002 | 01 | IL | RIALROAD MEDICARE | OTHER | 0407247 | 01 | IL | UNITED HEALTH | OTHER |