Healthcare Provider Details

I. General information

NPI: 1629377411
Provider Name (Legal Business Name): REBECCA ELISE POPHAM D.O.
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 03/20/2011
Last Update Date: 07/09/2021
Certification Date: 07/09/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

560 S LOOP RD
EDGEWOOD KY
41017-3405
US

IV. Provider business mailing address

560 S LOOP RD
EDGEWOOD KY
41017-3405
US

V. Phone/Fax

Practice location:
  • Phone: 859-301-2663
  • Fax: 859-817-7848
Mailing address:
  • Phone: 859-301-2663
  • Fax: 859-817-7848

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code207QS0010X
TaxonomySports Medicine (Family Medicine) Physician
License Number34.011667
License Number StateOH
# 2
Primary TaxonomyY
Taxonomy Code207QS0010X
TaxonomySports Medicine (Family Medicine) Physician
License Number03699
License Number StateKY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: