Provider Demographics
NPI:1619011467
Name:KOPPENHOEFER, MEGAN (MPT)
Entity Type:Individual
Prefix:
First Name:MEGAN
Middle Name:
Last Name:KOPPENHOEFER
Suffix:
Gender:F
Credentials:MPT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:790 REMINGTON BLVD
Mailing Address - Street 2:
Mailing Address - City:BOLINGBROOK
Mailing Address - State:IL
Mailing Address - Zip Code:60440-4909
Mailing Address - Country:US
Mailing Address - Phone:630-296-2223
Mailing Address - Fax:
Practice Address - Street 1:1226 S CANAL ST
Practice Address - Street 2:
Practice Address - City:CHICAGO
Practice Address - State:IL
Practice Address - Zip Code:60607-5213
Practice Address - Country:US
Practice Address - Phone:312-733-8958
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-02-16
Last Update Date:2011-07-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL070013197225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
ILP00846570OtherMEDICARE RAILROAD
ILP00931574OtherMEDICARE RAILROAD
IL212622012Medicare PIN
IL202845056Medicare PIN
ILP00846570OtherMEDICARE RAILROAD
IL212623010Medicare PIN
ILP00931574OtherMEDICARE RAILROAD