Provider Demographics
NPI:1386015030
Name:DR. MICHELLE M. COOPER, PA
Entity Type:Organization
Organization Name:DR. MICHELLE M. COOPER, PA
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:MICHELLE
Authorized Official - Middle Name:
Authorized Official - Last Name:COOPER
Authorized Official - Suffix:
Authorized Official - Credentials:OD
Authorized Official - Phone:864-901-5751
Mailing Address - Street 1:24 POTOMAC AVE
Mailing Address - Street 2:
Mailing Address - City:GREENVILLE
Mailing Address - State:SC
Mailing Address - Zip Code:29605-2118
Mailing Address - Country:US
Mailing Address - Phone:864-277-4420
Mailing Address - Fax:
Practice Address - Street 1:24 POTOMAC AVE
Practice Address - Street 2:
Practice Address - City:GREENVILLE
Practice Address - State:SC
Practice Address - Zip Code:29605-2118
Practice Address - Country:US
Practice Address - Phone:864-277-4420
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2015-10-07
Last Update Date:2015-10-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SC1038152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes152W00000XEye and Vision Services ProvidersOptometristGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
SCD10389Medicaid