Provider Demographics
NPI:1922704808
Name:COOPERCARE AZ, PLLC
Entity Type:Organization
Organization Name:COOPERCARE AZ, PLLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:MILISSA
Authorized Official - Middle Name:ANN
Authorized Official - Last Name:COOPER
Authorized Official - Suffix:
Authorized Official - Credentials:DO
Authorized Official - Phone:623-582-2355
Mailing Address - Street 1:20033 N 19TH AVE STE 111
Mailing Address - Street 2:
Mailing Address - City:PHOENIX
Mailing Address - State:AZ
Mailing Address - Zip Code:85027-4247
Mailing Address - Country:US
Mailing Address - Phone:623-582-2355
Mailing Address - Fax:
Practice Address - Street 1:20033 N 19TH AVE STE 111
Practice Address - Street 2:
Practice Address - City:PHOENIX
Practice Address - State:AZ
Practice Address - Zip Code:85027-4247
Practice Address - Country:US
Practice Address - Phone:623-582-2355
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2023-02-02
Last Update Date:2023-02-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
AZ354126Medicaid
AZAZ0394570OtherBLUE CROSS BLUE SHIELD