Provider Demographics
NPI:1073782660
Name:ROBERT G COOPER JR MD PC
Entity Type:Organization
Organization Name:ROBERT G COOPER JR MD PC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PHYSICIAN
Authorized Official - Prefix:
Authorized Official - First Name:ROBERT
Authorized Official - Middle Name:GRAHAM
Authorized Official - Last Name:COOPER
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:812-524-0505
Mailing Address - Street 1:505 S POPLAR ST
Mailing Address - Street 2:
Mailing Address - City:SEYMOUR
Mailing Address - State:IN
Mailing Address - Zip Code:47274-2960
Mailing Address - Country:US
Mailing Address - Phone:812-524-0505
Mailing Address - Fax:812-524-0515
Practice Address - Street 1:505 S POPLAR ST
Practice Address - Street 2:
Practice Address - City:SEYMOUR
Practice Address - State:IN
Practice Address - Zip Code:47274-2960
Practice Address - Country:US
Practice Address - Phone:812-524-0505
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-02-27
Last Update Date:2020-01-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN01060634A208600000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes208600000XAllopathic & Osteopathic PhysiciansSurgeryGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
IN200525780Medicaid
IN200525780Medicaid
IN233620Medicare PIN