Provider Demographics
NPI:1730129701
Name:COOPER, LYLE RAY (MD)
Entity Type:Individual
Prefix:
First Name:LYLE
Middle Name:RAY
Last Name:COOPER
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2100 STANTONSBURG ROAD
Mailing Address - Street 2:
Mailing Address - City:GREENVILLE
Mailing Address - State:NC
Mailing Address - Zip Code:27835-6028
Mailing Address - Country:US
Mailing Address - Phone:252-847-5473
Mailing Address - Fax:252-847-6255
Practice Address - Street 1:2100 STANTONSBURG ROAD
Practice Address - Street 2:
Practice Address - City:GREENVILLE
Practice Address - State:NC
Practice Address - Zip Code:27835-6028
Practice Address - Country:US
Practice Address - Phone:252-847-5473
Practice Address - Fax:252-847-6255
Is Sole Proprietor?:No
Enumeration Date:2006-06-07
Last Update Date:2009-10-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC25486208M00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208M00000XAllopathic & Osteopathic PhysiciansHospitalist
Provider Identifiers
StateIdentifier IDID TypeIssuer
NC24202OtherBCBS OF NC
NC8924202Medicaid
NC205572GMedicare PIN
NC8924202Medicaid