Provider Demographics
NPI:1619167749
Name:CURTIS V. COOPER PRIMARY HEALTH CARE,INC
Entity Type:Organization
Organization Name:CURTIS V. COOPER PRIMARY HEALTH CARE,INC
Other - Org Name:WESTSIDE URBAN HEALTH CENTER, INC
Other - Org Type:Former Legal Business Name
Authorized Official - Title/Position:EXECUTIVE DIRECTOR
Authorized Official - Prefix:MR
Authorized Official - First Name:LEON
Authorized Official - Middle Name:L
Authorized Official - Last Name:BURTON
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:912-527-1000
Mailing Address - Street 1:106 EAST BROAD STREET
Mailing Address - Street 2:
Mailing Address - City:SAVANNAH
Mailing Address - State:GA
Mailing Address - Zip Code:31401-2917
Mailing Address - Country:US
Mailing Address - Phone:912-527-1000
Mailing Address - Fax:912-527-1153
Practice Address - Street 1:840A HITCH DRIVE
Practice Address - Street 2:
Practice Address - City:SAVANNAH
Practice Address - State:GA
Practice Address - Zip Code:31401-3040
Practice Address - Country:US
Practice Address - Phone:912-232-9696
Practice Address - Fax:912-527-1153
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-07-25
Last Update Date:2009-11-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QF0400XAmbulatory Health Care FacilitiesClinic/CenterFederally Qualified Health Center (FQHC)
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA000463922CMedicaid
GA336179OtherWELLCARE
GA10063424OtherAMERIGROUP
GA336179OtherWELLCARE
GA10063424OtherAMERIGROUP
GA111833Medicare Oscar/Certification