Basic Information
Provider Information | |||||||||
NPI: | 1033192943 | ||||||||
EntityType: | 1 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: |   | ||||||||
LastName: | COOPER | ||||||||
FirstName: | TIMOTHY | ||||||||
MiddleName: | R | ||||||||
NamePrefix: |   | ||||||||
NameSuffix: |   | ||||||||
Credential: | MD | ||||||||
OtherOrganizationName: |   | ||||||||
OtherOrganizationType: |   | ||||||||
OtherLastName: |   | ||||||||
OtherFirstName: |   | ||||||||
OtherMiddleName: |   | ||||||||
OtherNamePrefix: |   | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: |   | ||||||||
OtherLastNameType: |   | ||||||||
Mailing Information | |||||||||
Address1: | 164 N BROADWAY | ||||||||
Address2: | 2845 GREENBRIER RD STE 340 | ||||||||
City: | GREEN BAY | ||||||||
State: | WI | ||||||||
PostalCode: | 543032728 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 9209654065 | ||||||||
FaxNumber: |   | ||||||||
Practice Location | |||||||||
Address1: | 2845 GREENBRIER RD STE 340 | ||||||||
Address2: |   | ||||||||
City: | GREEN BAY | ||||||||
State: | WI | ||||||||
PostalCode: | 543116519 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 9202888380 | ||||||||
FaxNumber: | 9202888385 | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 11/23/2005 | ||||||||
LastUpdateDate: | 03/22/2022 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: | M | ||||||||
AuthorizedOfficialLastName: |   | ||||||||
AuthorizedOfficialFirstName: |   | ||||||||
AuthorizedOfficialMiddleName: |   | ||||||||
AuthorizedOfficialTitleorPosition: |   | ||||||||
AuthorizedOfficialTelephone: |   | ||||||||
IsSoleProprietor: | N | ||||||||
IsOrganizationSubpart: |   | ||||||||
ParentOrganizationLBN: |   | ||||||||
AuthorizedOfficialNamePrefix: |   | ||||||||
AuthorizedOfficialNameSuffix: |   | ||||||||
AuthorizedOfficialCredential: |   | ||||||||
NPICertificationDate: | 03/22/2022 |
Taxonomy Information
Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207L00000X | 33935-020 | WI | N |   | Allopathic & Osteopathic Physicians | Anesthesiology |   | 208VP0000X | 33935 | WI | Y |   | Allopathic & Osteopathic Physicians | Pain Medicine | Pain Medicine |
ID Information
ID | Type | State | Issuer | Description | P00355798 | 01 | WI | RAILROAD | OTHER | 104896578 | 05 | MI |   | MEDICAID | 32037400 | 05 | WI |   | MEDICAID |