Healthcare Provider Details

I. General information

NPI: 1053637561
Provider Name (Legal Business Name): PETER BROOKS KOPPENHEFFER M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 04/09/2010
Last Update Date: 09/19/2018
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

48 SANDERSON ST
GREENFIELD MA
01301
US

IV. Provider business mailing address

280 CHESTNUT ST FL 2
SPRINGFIELD MA
01199-1619
US

V. Phone/Fax

Practice location:
  • Phone: 413-773-2022
  • Fax:
Mailing address:
  • Phone: 413-794-5700
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License Number269392
License Number StateNY
# 2
Primary TaxonomyY
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License Number275445
License Number StateMA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: