Provider Demographics
NPI:1073698478
Name:COOPER CLINIC, PA
Entity Type:Organization
Organization Name:COOPER CLINIC, PA
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:DIRECTOR, BUSINESS SERVICES
Authorized Official - Prefix:
Authorized Official - First Name:MELISSA
Authorized Official - Middle Name:G
Authorized Official - Last Name:ASTIN
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:479-274-2024
Mailing Address - Street 1:PO BOX 3528
Mailing Address - Street 2:
Mailing Address - City:FORT SMITH
Mailing Address - State:AR
Mailing Address - Zip Code:72913-3528
Mailing Address - Country:US
Mailing Address - Phone:479-274-2004
Mailing Address - Fax:479-274-2024
Practice Address - Street 1:6801 ROGERS AVE
Practice Address - Street 2:
Practice Address - City:FORT SMITH
Practice Address - State:AR
Practice Address - Zip Code:72903-4067
Practice Address - Country:US
Practice Address - Phone:479-274-2004
Practice Address - Fax:479-274-2024
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-10-25
Last Update Date:2015-08-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ARMC-0254291U00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes291U00000XLaboratoriesClinical Medical Laboratory
Provider Identifiers
StateIdentifier IDID TypeIssuer
AR110161709Medicaid
690001634OtherRR MEDICARE
AR110161709Medicaid