Provider Demographics
NPI:1477746873
Name:KOPEC, EWA (MS, PT)
Entity Type:Individual
Prefix:
First Name:EWA
Middle Name:
Last Name:KOPEC
Suffix:
Gender:F
Credentials:MS, PT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3545 LAKE AVE
Mailing Address - Street 2:SUITE 103
Mailing Address - City:WILMETTE
Mailing Address - State:IL
Mailing Address - Zip Code:60091-1058
Mailing Address - Country:US
Mailing Address - Phone:847-251-2028
Mailing Address - Fax:847-512-5064
Practice Address - Street 1:3545 LAKE AVE
Practice Address - Street 2:SUITE 103
Practice Address - City:WILMETTE
Practice Address - State:IL
Practice Address - Zip Code:60091-1058
Practice Address - Country:US
Practice Address - Phone:847-251-2028
Practice Address - Fax:847-512-5064
Is Sole Proprietor?:No
Enumeration Date:2007-08-20
Last Update Date:2008-07-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL70015237225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL01634372OtherBCI BCBS GROUP NO.
IL363396874OtherPEAK TAX ID
IL1618443OtherPEAK BCBS GROUP NO.
IL236963283001Medicaid
IL200573902OtherBCI TAX ID
IL363396874OtherPEAK TAX ID
IL01634372OtherBCI BCBS GROUP NO.
IL210877Medicare PIN