Healthcare Provider Details

I. General information

NPI: 1114992823
Provider Name (Legal Business Name): JIM KEVIN COPENHAVER M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 02/17/2006
Last Update Date: 08/14/2013
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

240 S MAIN ST EMERGENCY DEPARTMENT
WOLFEBORO NH
03894-4411
US

IV. Provider business mailing address

PO BOX 912 HUGGINS HOSPITAL
WOLFEBORO NH
03894-0912
US

V. Phone/Fax

Practice location:
  • Phone: 360-257-9403
  • Fax:
Mailing address:
  • Phone: 603-569-7575
  • Fax: 603-569-7564

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code207P00000X
TaxonomyEmergency Medicine Physician
License Number16158
License Number StateNH
# 2
Primary TaxonomyN
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License NumberMDOOO23980
License Number StateWA
# 3
Primary TaxonomyY
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License Number16158
License Number StateNH

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: