Provider Demographics
NPI:1710214010
Name:COOPER CLINIC PA
Entity Type:Organization
Organization Name:COOPER CLINIC PA
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CEO
Authorized Official - Prefix:
Authorized Official - First Name:CURTIS
Authorized Official - Middle Name:
Authorized Official - Last Name:RALSTON
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:479-274-2000
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:479-274-2000
Mailing Address - Fax:479-274-2194
Practice Address - Street 1:600 S 21ST ST
Practice Address - Street 2:
Practice Address - City:FORT SMITH
Practice Address - State:AR
Practice Address - Zip Code:72901-3915
Practice Address - Country:US
Practice Address - Phone:479-274-6750
Practice Address - Fax:479-434-5395
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2009-11-06
Last Update Date:2015-09-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ARMC-0254213E00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes213E00000XPodiatric Medicine & Surgery Service ProvidersPodiatristGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
AR191274716Medicaid
AR191274716Medicaid
AR0384730022Medicare NSC