1366624124 NPI number — GEORGE L COOPER MD

Table of Contents

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1366624124 NPI number — GEORGE L COOPER MD

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
GEORGE L COOPER MD
Provider Last Name:
Provider First Name:
Provider Middle Name:
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
Provider Gender Code:

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1366624124
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
07/21/2008
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
2139 VALLEYGATE DR STE 101A
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
FAYETTEVILLE
Provider Business Mailing Address State Name:
NC
Provider Business Mailing Address Postal Code:
28304-3666
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
910-323-2002
Provider Business Mailing Address Fax Number:
910-323-3477

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
2139 VALLEYGATE DR STE 101A
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
FAYETTEVILLE
Provider Business Practice Location Address State Name:
NC
Provider Business Practice Location Address Postal Code:
28304-3666
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
910-323-2002
Provider Business Practice Location Address Fax Number:
910-323-3477
Provider Enumeration Date:
12/03/2007

Additional Information

Authorized Official

Authorized Official Last Name:
COOPER
Authorized Official First Name:
GEORGE
Authorized Official Middle Name:
L
Authorized Official Title or Position:
OWNER
Authorized Official Telephone Number:
910-323-2002

Provider Taxonomy Codes

  • Taxonomy code: 207W00000X ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .
  • Taxonomy code: 332H00000X , with the licence number: 1226 , registered in the state of NC ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .

Other Provider's Identifiers (legacy, non-NPI)

  • Identifier: 89093AG , issued by the state of ( NC ) . This identifiers is of the category "MEDICAID".
  • Identifier: 891083N , issued by the state of ( NC ) . This identifiers is of the category "MEDICAID".




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