Provider Demographics
NPI:1588812028
Name:WALTER E KOPPENBRINK MD LTD
Entity Type:Organization
Organization Name:WALTER E KOPPENBRINK MD LTD
Other - Org Name:KOPPENBRINK INTERNAL MEDICINE
Other - Org Type:Doing Business As
Authorized Official - Title/Position:PRACTICE MANAGER/CORP SEC
Authorized Official - Prefix:
Authorized Official - First Name:JOAN
Authorized Official - Middle Name:
Authorized Official - Last Name:KOPPENBRINK
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:602-228-4051
Mailing Address - Street 1:4350 E CAMELBACK RD
Mailing Address - Street 2:STE F-100
Mailing Address - City:PHOENIX
Mailing Address - State:AZ
Mailing Address - Zip Code:85018-2701
Mailing Address - Country:US
Mailing Address - Phone:602-955-8700
Mailing Address - Fax:602-553-8142
Practice Address - Street 1:4350 E CAMELBACK RD
Practice Address - Street 2:STE F-100
Practice Address - City:PHOENIX
Practice Address - State:AZ
Practice Address - Zip Code:85018-2701
Practice Address - Country:US
Practice Address - Phone:602-955-8700
Practice Address - Fax:602-553-8142
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-09-08
Last Update Date:2015-11-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZ11324207R00000X, 207RG0100X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207RG0100XAllopathic & Osteopathic PhysiciansInternal MedicineGastroenterologyGroup - Multi-Specialty
No207R00000XAllopathic & Osteopathic PhysiciansInternal MedicineGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
D44130Medicare UPIN
102723Medicare PIN