Provider Demographics
NPI:1003999228
Name:COOPER, SCOTT A (MD)
Entity Type:Individual
Prefix:
First Name:SCOTT
Middle Name:A
Last Name:COOPER
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Mailing Address - Street 1:405 W JACKSON ST
Mailing Address - Street 2:MEMORIAL HOSPITAL
Mailing Address - City:CARBONDALE
Mailing Address - State:IL
Mailing Address - Zip Code:62901-1462
Mailing Address - Country:US
Mailing Address - Phone:618-549-0721
Mailing Address - Fax:618-529-0449
Practice Address - Street 1:405 W JACKSON ST
Practice Address - Street 2:MEMORIAL HOSPITAL
Practice Address - City:CARBONDALE
Practice Address - State:IL
Practice Address - Zip Code:62901-1462
Practice Address - Country:US
Practice Address - Phone:618-549-0721
Practice Address - Fax:618-529-0449
Is Sole Proprietor?:No
Enumeration Date:2006-10-23
Last Update Date:2020-10-13
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
IL036064861207P00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207P00000XAllopathic & Osteopathic PhysiciansEmergency Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL036064861Medicaid