1194729525 NPI number — DR. ROBERT WAYNE COOPER M.D.

Table of content: DR. ROBERT WAYNE COOPER M.D. (NPI 1194729525)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1194729525 NPI number — DR. ROBERT WAYNE COOPER M.D.

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
COOPER
Provider First Name:
ROBERT
Provider Middle Name:
WAYNE
Provider Name Prefix Text:
DR.
Provider Name Suffix Text:
Provider Credential Text:
M.D.
Provider Gender Code:
M

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:
1194729525
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
03/12/2025
NPI Deactivation Reason Code:
NPI Deactivation Date:
03/16/2006
NPI Reactivation Date:
03/22/2006

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
PO BOX 247
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
JELLICO
Provider Business Mailing Address State Name:
TN
Provider Business Mailing Address Postal Code:
37762-0247
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
606-549-2933
Provider Business Mailing Address Fax Number:
606-549-3036

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
475 N HIGHWAY 25 W # WN
Provider Second Line Business Practice Location Address:
SUITE 100
Provider Business Practice Location Address City Name:
WILLIAMSBURG
Provider Business Practice Location Address State Name:
KY
Provider Business Practice Location Address Postal Code:
40769-1576
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
606-549-2933
Provider Business Practice Location Address Fax Number:
606-549-3036
Provider Enumeration Date:
06/13/2005

Additional Information

Authorized Official

Authorized Official Last Name:
Authorized Official First Name:
Authorized Official Middle Name:
Authorized Official Title or Position:
Authorized Official Telephone Number:

Provider Taxonomy Codes

  • Taxonomy code: 207Q00000X , with the licence number:  18598 , registered in the state of KY ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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

  • Identifier: 201533510 , issued by the state of ( MO ) . This identifiers is of the category "MEDICAID".
  • Identifier: 135570021 . This is a "MEDICARE PTAN" identifier , issued by the state of ( MO ) . This identifiers is of the category "OTHER".
  • Identifier: 3518 . This is a "BLUE CROSS/BLUE SHIELD" identifier , issued by the state of ( MO ) . This identifiers is of the category "OTHER".
  • Identifier: P00792573 . This is a "RAIL ROAD MEDICARE" identifier , issued by the state of ( MO ) . This identifiers is of the category "OTHER".
  • Identifier: Q020836 , issued by the state of ( TN ) . This identifiers is of the category "MEDICAID".
  • Identifier: 115556 . This is a "HEALTHLINK" identifier , issued by the state of ( MO ) . This identifiers is of the category "OTHER".
  • Identifier: 7100398340 , issued by the state of ( KY ) . This identifiers is of the category "MEDICAID".




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