1063768901 NPI number — COOPER CLINIC PA

Table of content: (NPI 1063768901)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1063768901 NPI number — COOPER CLINIC PA

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
COOPER CLINIC PA
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:
1063768901
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
09/01/2015
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
PO BOX 3528
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
FORT SMITH
Provider Business Mailing Address State Name:
AR
Provider Business Mailing Address Postal Code:
72913-3528
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
479-274-2000
Provider Business Mailing Address Fax Number:
479-274-2194

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
5004 S U ST
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
FORT SMITH
Provider Business Practice Location Address State Name:
AR
Provider Business Practice Location Address Postal Code:
72903-3600
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
479-274-6700
Provider Business Practice Location Address Fax Number:
479-484-4768
Provider Enumeration Date:
07/30/2012

Additional Information

Authorized Official

Authorized Official Last Name:
RALSTON
Authorized Official First Name:
CURTIS
Authorized Official Middle Name:
Authorized Official Title or Position:
CEO
Authorized Official Telephone Number:
479-274-2000

Provider Taxonomy Codes

  • Taxonomy code: 213E00000X , with the licence number:  84 , registered in the state of AR ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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

  • Identifier: 191272716 , issued by the state of ( AR ) . This identifiers is of the category "MEDICAID".




Copyright © 2007-2025 www.npivalidator.com