=====================================================
General NPI Number Information
=====================================================
NPI Number | 1083731277
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | PREMIER ENT AND ALLERGY, PLLC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 03/23/2007
-----------------------------------------------------
Last Update Date | 01/10/2020
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 2429 BUSH RIDGE DR STE 103
-----------------------------------------------------
City | LOUISVILLE
-----------------------------------------------------
State | KY
-----------------------------------------------------
Zip | 40245-5914
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 502-893-3683
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 2429 BUSH RIDGE DR STE 103
-----------------------------------------------------
City | LOUISVILLE
-----------------------------------------------------
State | KY
-----------------------------------------------------
Zip | 40245-5914
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 502-893-3683
-----------------------------------------------------
Fax | 502-893-1662
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | OWNER
-----------------------------------------------------
Name | DR. CARL DAVID COPPOLA
-----------------------------------------------------
Credential | MD
-----------------------------------------------------
Telephone | 502-893-3683
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 207Y00000X
-----------------------------------------------------
Taxonomy Name | Otolaryngology Physician
-----------------------------------------------------
License Number | 28995
-----------------------------------------------------
License Number State | KY
-----------------------------------------------------