Healthcare Provider Details

I. General information

NPI: 1912943499
Provider Name (Legal Business Name): RICHARD A KOEPKE,DO,PLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 06/21/2006
Last Update Date: 08/22/2020
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3309 QUAIL HOLLOW DR SUITE A
LAMBERTVILLE MI
48144-8688
US

IV. Provider business mailing address

3309 QUAIL HOLLOW DR SUITE A
LAMBERTVILLE MI
48144-8688
US

V. Phone/Fax

Practice location:
  • Phone: 734-854-5441
  • Fax: 734-854-7441
Mailing address:
  • Phone: 734-854-5441
  • Fax: 734-854-7441

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code174400000X
TaxonomySpecialist
License Number5101011998
License Number StateMI

VIII. Authorized Official

Name: DR. RICHARD A KOEPKE
Title or Position: OWNER
Credential: D.O.
Phone: 734-854-5441