Healthcare Provider Details

I. General information

NPI: 1568835445
Provider Name (Legal Business Name): KOPP MEDICAL LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 11/02/2015
Last Update Date: 06/01/2021
Certification Date: 01/18/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

6720 GRELOT ROAD SUITE A
MOBILE AL
36695-2676
US

IV. Provider business mailing address

6720 GRELOT ROAD SUITE A
MOBILE AL
36695-2676
US

V. Phone/Fax

Practice location:
  • Phone: 251-633-5155
  • Fax: 251-633-5125
Mailing address:
  • Phone: 251-633-5155
  • Fax: 251-633-5125

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code2081P2900X
TaxonomyPain Medicine (Physical Medicine & Rehabilitation) Physician
License Number30966
License Number StateAL

VIII. Authorized Official

Name: DR. THEODORE MICHAEL KOPP
Title or Position: OWNER
Credential: MD
Phone: 251-633-5155