=====================================================
General NPI Number Information
=====================================================
NPI Number | 1245455740
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | KRZYSZTOF KOPEC MD
-----------------------------------------------------
Gender | Male
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 04/17/2007
-----------------------------------------------------
Last Update Date | 08/09/2012
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 21 SOUTH RD SUITE 100
-----------------------------------------------------
City | FARMINGTON
-----------------------------------------------------
State | CT
-----------------------------------------------------
Zip | 06032-2482
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 860-409-4567
-----------------------------------------------------
Fax | 860-409-4846
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 2139 SILAS DEANE HWY
-----------------------------------------------------
City | ROCKY HILL
-----------------------------------------------------
State | CT
-----------------------------------------------------
Zip | 06067-2336
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 860-257-4131
-----------------------------------------------------
Fax | 860-257-4519
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 207R00000X
-----------------------------------------------------
Taxonomy Name | Internal Medicine Physician
-----------------------------------------------------
License Number | LP00875
-----------------------------------------------------
License Number State | RI
-----------------------------------------------------
Taxonomy #2
-----------------------------------------------------
Taxonomy Code | 207RG0100X
-----------------------------------------------------
Taxonomy Name | Gastroenterology Physician
-----------------------------------------------------
License Number | 050994
-----------------------------------------------------
License Number State | CT
-----------------------------------------------------