NPIMap

Individual provider Active NPI

Carolyn S Koppenol, M.D.

  • Psychiatry Physician
  • Hillman, MI
National Provider Identifier
1003964255
Registry record updated Oct 9, 2012
On this page

Key facts

NPPES NPI Registry
Primary specialty
Psychiatry PhysicianTaxonomy code 2084P0800X
License
4301046030 Issued in MI
Practice address
15774 State Street
Hillman, MI 49746-0427
Phone
(989) 742-4583
Fax
(989) 742-2183
NPI assigned
Jan 6, 2007
Sex
Female
Sole proprietor
No

NPPES NPI Registry

Updated by the provider on Oct 9, 2012

Registry information is reported by the provider to CMS and is not verified. About this source

Specialties & licenses 1

Specialty (taxonomy)CodeLicenseStatePrimary
Psychiatry Physician 2084P0800X 4301046030 MI Primary

Addresses

Primary practice location

15774 State Street
Hillman, MI 49746-0427

Mailing address

PO Box 427
Hillman, MI 49746-0427
Phone (989) 354-2197

Other identifiers 2

IdentifierTypeStateIssuer
CK046030OtherMISTATE LICENSE NUMBER
5104939MedicaidMI

Medicare participation

Medicare enrollment files
Medicare fee-for-service enrollment
Enrolled in MI
Eligible to order & refer
  • Part B services
  • Medical equipment
  • Home health
  • Power mobility devices
  • Hospice
Green means eligible to order or refer.

Enrollment records 1

Enrollment IDStateProvider typePAC IDDetails
I20041008000981 MI Practitioner - Psychiatry 3779542220 Reassigns benefits to 1 organization

Care Compare profile

Medicare Care Compare
Specialty
Psychiatry
Education
Washington University School of Medicine, 1978
Medicare assignment
Accepts the Medicare-approved amount as payment in full
Telehealth
Offers telehealth services
Group practices
Pine Rest Christian Mental Health Services 354 clinicians

Practice addresses (Care Compare)

4211 Pkwy Place SW
Grandville, MI 49418-2385
Phone (616) 222-3700

National Provider Directory

National Provider Directory
Medicare enrollment (NPD)
Enrolled
Credentials
Doctor of Medicine

Practice roles

OrganizationSpecialtyStatusNew patients
Pine Rest Christian Mental Health Services Psychiatry CurrentSince Jun 29, 2015 Accepting new patients
Pine Rest Christian Mental Health Services CurrentSince Jun 29, 2015 Accepting new patients
Pine Rest Christian Mental Health Services Current Accepting new patients
Northeast Michigan Community Mental Health Authority PastSince Jul 20, 2005 Accepting new patients

Locations

4211 Parkway Place Dr SW
Grandville, MI 49418
Phone (616) 222-3700

17325 Van Wagoner Rd
Spring Lake, MI 49456
Phone (616) 846-9100

300 68th St SE
Wyoming, MI 49548
Phone (616) 455-5000

Organizations & group practices 9

Organizations this provider is connected to: Medicare benefit reassignments (the organization bills Medicare for this provider’s services), Care Compare group memberships and National Provider Directory roles.

NPI Registry JSON

The complete NPPES record for this NPI in the NPI Registry API format.

{
    "created_epoch": "1168041600000",
    "enumeration_type": "NPI-1",
    "last_updated_epoch": "1349740800000",
    "number": "1003964255",
    "addresses": [
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "MAILING",
            "address_type": "DOM",
            "address_1": "PO BOX 427",
            "city": "HILLMAN",
            "state": "MI",
            "postal_code": "497460427",
            "telephone_number": "989-354-2197",
            "fax_number": "989-356-6524"
        },
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "LOCATION",
            "address_type": "DOM",
            "address_1": "15774 STATE STREET",
            "city": "HILLMAN",
            "state": "MI",
            "postal_code": "497460427",
            "telephone_number": "989-742-4583",
            "fax_number": "989-742-2183"
        }
    ],
    "practiceLocations": [],
    "basic": {
        "last_name": "KOPPENOL",
        "first_name": "CAROLYN",
        "middle_name": "S",
        "name_prefix": "Ms.",
        "credential": "M.D.",
        "sole_proprietor": "NO",
        "sex": "F",
        "enumeration_date": "2007-01-06",
        "last_updated": "2012-10-09",
        "status": "A"
    },
    "taxonomies": [
        {
            "code": "2084P0800X",
            "taxonomy_group": "",
            "desc": "Psychiatry & Neurology, Psychiatry",
            "state": "MI",
            "license": "4301046030",
            "primary": true
        }
    ],
    "identifiers": [
        {
            "code": "01",
            "desc": "Other (non-Medicare)",
            "issuer": "STATE LICENSE NUMBER",
            "identifier": "CK046030",
            "state": "MI"
        },
        {
            "code": "05",
            "desc": "MEDICAID",
            "issuer": null,
            "identifier": "5104939",
            "state": "MI"
        }
    ],
    "endpoints": [],
    "other_names": []
}

Other providers in Hillman, MI

Sources for this page

Verify at the official NPI Registry.