Basic Information
| Provider Information | |||||||||
| NPI: | 1073698478 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | COOPER CLINIC, PA | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 3528 | ||||||||
| Address2: | |||||||||
| City: | FORT SMITH | ||||||||
| State: | AR | ||||||||
| PostalCode: | 729133528 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4792742004 | ||||||||
| FaxNumber: | 4792742024 | ||||||||
| Practice Location | |||||||||
| Address1: | 6801 ROGERS AVE | ||||||||
| Address2: | |||||||||
| City: | FORT SMITH | ||||||||
| State: | AR | ||||||||
| PostalCode: | 729034067 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4792742004 | ||||||||
| FaxNumber: | 4792742024 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 10/25/2006 | ||||||||
| LastUpdateDate: | 08/28/2015 | ||||||||
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| AuthorizedOfficialLastName: | ASTIN | ||||||||
| AuthorizedOfficialFirstName: | MELISSA | ||||||||
| AuthorizedOfficialMiddleName: | G | ||||||||
| AuthorizedOfficialTitleorPosition: | DIRECTOR, BUSINESS SERVICES | ||||||||
| AuthorizedOfficialTelephone: | 4792742024 | ||||||||
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| IsOrganizationSubpart: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 291U00000X | MC-0254 | AR | Y | Laboratories | Clinical Medical Laboratory |
ID Information
| ID | Type | State | Issuer | Description | 110161709 | 05 | AR | MEDICAID | 690001634 | 01 | RR MEDICARE | OTHER |