MEDICARE: MS. CAROLYN S KOPPENOL M.D.

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	2084P0800X	Psychiatry Physician	4301046030	MI

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	CK046030	OTHER	MI	STATE LICENSE NUMBER
2	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program

General Provider Information

NPI Number	:	1003964255
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MS. CAROLYN S KOPPENOL M.D.

Provider Business Mailing Address
First Line	:	PO BOX 427
Second Line	:
City	:	HILLMAN
State	:	MI
Zip	:	49746-0427
Country	:	US
Telephone Number	:	989-354-2197
Fax Number	:	989-356-6524

Provider Business Practice Location Address
First Line	:	15774 STATE STREET
Second Line	:
City	:	HILLMAN
State	:	MI
Zip	:	49746-0427
Country	:	US
Telephone Number	:	989-742-4583
Fax Number	:	989-742-2183

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	01/06/2007
Last Update Date	:	10/09/2012

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