Basic Information
| Provider Information | |||||||||
| NPI: | 1376756023 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | CURTIS V. COOPER PRIMARY HEALTH CARE, INC. | ||||||||
| LastName: | |||||||||
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| Mailing Information | |||||||||
| Address1: | 106 E BROAD ST | ||||||||
| Address2: | |||||||||
| City: | SAVANNAH | ||||||||
| State: | GA | ||||||||
| PostalCode: | 314012917 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9125271000 | ||||||||
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| Practice Location | |||||||||
| Address1: | 2 ROBERTS ST | ||||||||
| Address2: | |||||||||
| City: | SAVANNAH | ||||||||
| State: | GA | ||||||||
| PostalCode: | 314083524 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9125271000 | ||||||||
| FaxNumber: | |||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 05/08/2007 | ||||||||
| LastUpdateDate: | 01/27/2020 | ||||||||
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| ProviderGenderCode: | |||||||||
| AuthorizedOfficialLastName: | DANIELS | ||||||||
| AuthorizedOfficialFirstName: | EARLENE | ||||||||
| AuthorizedOfficialMiddleName: | JOINER | ||||||||
| AuthorizedOfficialTitleorPosition: | CHIEF ADMINISTRAIVE OFFICER | ||||||||
| AuthorizedOfficialTelephone: | 9125271088 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
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| NPICertificationDate: | 01/27/2020 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 3336C0002X | PHRE005935 | GA | Y | Suppliers | Pharmacy | Clinic Pharmacy |
ID Information
| ID | Type | State | Issuer | Description | 000326466A | 05 | GA | MEDICAID |