1386749182 NPI number — EVERETT BRUEN COOPER JR. M.D.

Table of content: EVERETT BRUEN COOPER JR. M.D. (NPI 1386749182)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1386749182 NPI number — EVERETT BRUEN COOPER JR. M.D.

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
COOPER
Provider First Name:
EVERETT
Provider Middle Name:
BRUEN
Provider Name Prefix Text:
Provider Name Suffix Text:
JR.
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:
1386749182
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
07/08/2007
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
1353 WATERSTON DR
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
EVANS
Provider Business Mailing Address State Name:
GA
Provider Business Mailing Address Postal Code:
30809-5038
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
706-650-7619
Provider Business Mailing Address Fax Number:

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
1 FREEDOM WAY
Provider Second Line Business Practice Location Address:
VA MEDICAL CENTER
Provider Business Practice Location Address City Name:
AUGUSTA
Provider Business Practice Location Address State Name:
GA
Provider Business Practice Location Address Postal Code:
30904-6258
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
706-733-0188
Provider Business Practice Location Address Fax Number:
706-481-6729
Provider Enumeration Date:
09/14/2006

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: 207R00000X , with the licence number:  043351 , registered in the state of GA ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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