Healthcare Provider Details

I. General information

NPI: 1619961984
Provider Name (Legal Business Name): RON M KOPPENHOEFER MD
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 09/01/2005
Last Update Date: 05/15/2008
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

8333 MONTGOMERY RD
CINCINNATI OH
45236-2227
US

IV. Provider business mailing address

8333 MONTGOMERY RD
CINCINNATI OH
45236-2227
US

V. Phone/Fax

Practice location:
  • Phone: 573-792-5600
  • Fax: 573-792-5604
Mailing address:
  • Phone: 573-792-5600
  • Fax: 573-792-5604

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code208100000X
TaxonomyPhysical Medicine & Rehabilitation Physician
License Number3537270
License Number StateOH
# 2
Primary TaxonomyN
Taxonomy Code208100000X
TaxonomyPhysical Medicine & Rehabilitation Physician
License Number20708
License Number StateKY
# 3
Primary TaxonomyN
Taxonomy Code208100000X
TaxonomyPhysical Medicine & Rehabilitation Physician
License Number4301064876
License Number StateMI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: