Healthcare Provider Details

I. General information

NPI: 1740524073
Provider Name (Legal Business Name): BRIAN H KOPICKO DPT
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 11/27/2012
Last Update Date: 11/27/2012
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

925 CHESTNUT ST 5TH FLOOR
PHILADELPHIA PA
19107-4216
US

IV. Provider business mailing address

120 W GERMANTOWN PIKE SUITE 100
PLYMOUTH MEETING PA
19462-1420
US

V. Phone/Fax

Practice location:
  • Phone: 800-419-8093
  • Fax: 215-503-0540
Mailing address:
  • Phone: 610-270-0370
  • Fax: 610-270-0374

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code2251X0800X
TaxonomyOrthopedic Physical Therapist
License NumberPT022482
License Number StatePA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: