MEDICARE: KEN C HOPPER MD PA

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	H5512	TX

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	00D38A	OTHER	TX	MEDIARE ID

General Provider Information

NPI Number	:	1669640686
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	KEN C HOPPER MD PA

Provider Business Mailing Address
First Line	:	801 ROAD TO SIX FLAGS W STE 145
Second Line	:
City	:	ARLINGTON
State	:	TX
Zip	:	76012-2600
Country	:	US
Telephone Number	:	817-274-8800
Fax Number	:	817-274-8806

Provider Business Practice Location Address
First Line	:	801 ROAD TO SIX FLAGS W STE 145
Second Line	:
City	:	ARLINGTON
State	:	TX
Zip	:	76012-2600
Country	:	US
Telephone Number	:	817-274-8800
Fax Number	:	817-274-8806

Authorized Official
Title or Position	:	OWNER
Name	:	DR. KEN C HOPPER
Credential	:	M.D
Telephone Number	:	817-274-8800

Provider Enumeration Date	:	02/12/2008
Last Update Date	:	02/12/2008

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