Provider Demographics
NPI:1831391424
Name:JAMES DAVID KOEPSELL MD SC
Entity type:Organization
Organization Name:JAMES DAVID KOEPSELL MD SC
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:OFFICE MANAGER
Authorized Official - Prefix:MRS
Authorized Official - First Name:SHIRLEY
Authorized Official - Middle Name:E
Authorized Official - Last Name:KITTLE-KRAUS
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:815-962-0633
Mailing Address - Street 1:2829 GLENWOOD AVE
Mailing Address - Street 2:
Mailing Address - City:ROCKFORD
Mailing Address - State:IL
Mailing Address - Zip Code:61101-3542
Mailing Address - Country:US
Mailing Address - Phone:815-962-0633
Mailing Address - Fax:815-962-0142
Practice Address - Street 1:2829 GLENWOOD AVE
Practice Address - Street 2:
Practice Address - City:ROCKFORD
Practice Address - State:IL
Practice Address - Zip Code:61101-3542
Practice Address - Country:US
Practice Address - Phone:815-962-0633
Practice Address - Fax:815-962-0142
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-06-05
Last Update Date:2008-12-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal MedicineGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL1831391424OtherGROUP
IL209203Medicare PIN