1619167749 NPI number — CURTIS V. COOPER PRIMARY HEALTH CARE,INC

Table of content: (NPI 1619167749)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1619167749 NPI number — CURTIS V. COOPER PRIMARY HEALTH CARE,INC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
CURTIS V. COOPER PRIMARY HEALTH CARE,INC
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:
WESTSIDE URBAN HEALTH CENTER, INC
Provider Other Organization Name Type Code:
4
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:
1619167749
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
11/24/2009
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
106 EAST BROAD STREET
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
SAVANNAH
Provider Business Mailing Address State Name:
GA
Provider Business Mailing Address Postal Code:
31401-2917
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
912-527-1000
Provider Business Mailing Address Fax Number:
912-527-1153

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
840A HITCH DRIVE
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
SAVANNAH
Provider Business Practice Location Address State Name:
GA
Provider Business Practice Location Address Postal Code:
31401-3040
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
912-232-9696
Provider Business Practice Location Address Fax Number:
912-527-1153
Provider Enumeration Date:
07/25/2007

Additional Information

Authorized Official

Authorized Official Last Name:
BURTON
Authorized Official First Name:
LEON
Authorized Official Middle Name:
L.
Authorized Official Title or Position:
EXECUTIVE DIRECTOR
Authorized Official Telephone Number:
912-527-1000

Provider Taxonomy Codes

  • Taxonomy code: 261QF0400X ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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

  • Identifier: 000463922C , issued by the state of ( GA ) . This identifiers is of the category "MEDICAID".
  • Identifier: 336179 . This is a "WELLCARE" identifier , issued by the state of ( GA ) . This identifiers is of the category "OTHER".
  • Identifier: 10063424 . This is a "AMERIGROUP" identifier , issued by the state of ( GA ) . This identifiers is of the category "OTHER".




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