Provider Demographics
NPI:1083731277
Name:PREMIER ENT AND ALLERGY, PLLC
Entity Type:Organization
Organization Name:PREMIER ENT AND ALLERGY, PLLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:CARL
Authorized Official - Middle Name:DAVID
Authorized Official - Last Name:COPPOLA
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:502-893-3683
Mailing Address - Street 1:2429 BUSH RIDGE DR STE 103
Mailing Address - Street 2:
Mailing Address - City:LOUISVILLE
Mailing Address - State:KY
Mailing Address - Zip Code:40245-5914
Mailing Address - Country:US
Mailing Address - Phone:502-893-3683
Mailing Address - Fax:502-893-1662
Practice Address - Street 1:2429 BUSH RIDGE DR STE 103
Practice Address - Street 2:
Practice Address - City:LOUISVILLE
Practice Address - State:KY
Practice Address - Zip Code:40245-5914
Practice Address - Country:US
Practice Address - Phone:502-893-3683
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-03-23
Last Update Date:2020-01-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KY28995207Y00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207Y00000XAllopathic & Osteopathic PhysiciansOtolaryngologyGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
KY000000045669OtherBCBS
KYCB0478OtherRR MEDICARE
KY1052620OtherPASSPORT
KY64289952Medicaid
KY1052620OtherPASSPORT
KY1278703Medicare ID - Type Unspecified