Basic Information
Provider Information | |||||||||
NPI: | 1376546150 | ||||||||
EntityType: | 1 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: |   | ||||||||
LastName: | KOPLON | ||||||||
FirstName: | MICHAEL | ||||||||
MiddleName: | D. | ||||||||
NamePrefix: |   | ||||||||
NameSuffix: |   | ||||||||
Credential: | M.D. | ||||||||
OtherOrganizationName: |   | ||||||||
OtherOrganizationType: |   | ||||||||
OtherLastName: |   | ||||||||
OtherFirstName: |   | ||||||||
OtherMiddleName: |   | ||||||||
OtherNamePrefix: |   | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: |   | ||||||||
OtherLastNameType: |   | ||||||||
Mailing Information | |||||||||
Address1: | P O BOX 1000 DEPT 351 | ||||||||
Address2: |   | ||||||||
City: | MEMPHIS | ||||||||
State: | TN | ||||||||
PostalCode: | 381480001 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 9017589900 | ||||||||
FaxNumber: | 9017522335 | ||||||||
Practice Location | |||||||||
Address1: | 1265 UNION AVE | ||||||||
Address2: |   | ||||||||
City: | MEMPHIS | ||||||||
State: | TN | ||||||||
PostalCode: | 381043415 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 9015162362 | ||||||||
FaxNumber: | 9015168254 | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 05/24/2005 | ||||||||
LastUpdateDate: | 05/01/2018 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: | M | ||||||||
AuthorizedOfficialLastName: |   | ||||||||
AuthorizedOfficialFirstName: |   | ||||||||
AuthorizedOfficialMiddleName: |   | ||||||||
AuthorizedOfficialTitleorPosition: |   | ||||||||
AuthorizedOfficialTelephone: |   | ||||||||
IsSoleProprietor: | N | ||||||||
IsOrganizationSubpart: |   | ||||||||
ParentOrganizationLBN: |   | ||||||||
AuthorizedOfficialNamePrefix: |   | ||||||||
AuthorizedOfficialNameSuffix: |   | ||||||||
AuthorizedOfficialCredential: |   | ||||||||
NPICertificationDate: |   |
Taxonomy Information
Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 208M00000X | 34018 | TN | N |   | Allopathic & Osteopathic Physicians | Hospitalist |   | 207R00000X | MD34018 | TN | Y |   | Allopathic & Osteopathic Physicians | Internal Medicine |   |
ID Information
ID | Type | State | Issuer | Description | 3149825 | 01 | TN | BLUE CROSS BLUE SHIELD | OTHER | 1985645 | 01 |   | UNITED HEALTHCARE | OTHER | 7683058 | 01 |   | AETNA | OTHER | 8840602005 | 01 |   | CIGNA | OTHER |