Healthcare Provider Details

I. General information

NPI: 1467497495
Provider Name (Legal Business Name): JOHN HARRISON KOPCHICK M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/16/2006
Last Update Date: 03/17/2018
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2240 TEAL CT SE
GRAND RAPIDS MI
49546-7939
US

IV. Provider business mailing address

2240 TEAL CT SE
GRAND RAPIDS MI
49546-7939
US

V. Phone/Fax

Practice location:
  • Phone: 616-635-1220
  • Fax:
Mailing address:
  • Phone: 616-635-1220
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code208800000X
TaxonomyUrology Physician
License Number58797
License Number StateMN
# 2
Primary TaxonomyY
Taxonomy Code208800000X
TaxonomyUrology Physician
License Number4301043886
License Number StateMI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: