Basic Information
| Provider Information | |||||||||
| NPI: | 1710214010 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| 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: | 4792742000 | ||||||||
| FaxNumber: | 4792742194 | ||||||||
| Practice Location | |||||||||
| Address1: | 600 S 21ST ST | ||||||||
| Address2: | |||||||||
| City: | FORT SMITH | ||||||||
| State: | AR | ||||||||
| PostalCode: | 729013915 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4792746750 | ||||||||
| FaxNumber: | 4794345395 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 11/06/2009 | ||||||||
| LastUpdateDate: | 09/01/2015 | ||||||||
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| AuthorizedOfficialLastName: | RALSTON | ||||||||
| AuthorizedOfficialFirstName: | CURTIS | ||||||||
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| AuthorizedOfficialTitleorPosition: | CEO | ||||||||
| AuthorizedOfficialTelephone: | 4792742000 | ||||||||
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| IsOrganizationSubpart: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 213E00000X | MC-0254 | AR | Y | 193200000X MULTI-SPECIALTY GROUP | Podiatric Medicine & Surgery Service Providers | Podiatrist |
ID Information
| ID | Type | State | Issuer | Description | 191274716 | 05 | AR | MEDICAID |