Provider Demographics
NPI:1255515862
Name:W THOMAS COOPER, MD PS
Entity type:Organization
Organization Name:W THOMAS COOPER, MD PS
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:W THOMAS
Authorized Official - Middle Name:
Authorized Official - Last Name:COOPER
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:509-547-9521
Mailing Address - Street 1:1200 N 14TH AVE
Mailing Address - Street 2:SUITE 245
Mailing Address - City:PASCO
Mailing Address - State:WA
Mailing Address - Zip Code:99301-4182
Mailing Address - Country:US
Mailing Address - Phone:509-547-9521
Mailing Address - Fax:509-547-5983
Practice Address - Street 1:1200 N 14TH AVE
Practice Address - Street 2:SUITE 245
Practice Address - City:PASCO
Practice Address - State:WA
Practice Address - Zip Code:99301-4182
Practice Address - Country:US
Practice Address - Phone:509-547-9521
Practice Address - Fax:509-547-5983
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-12-19
Last Update Date:2008-01-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WAMD00020136208D00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes208D00000XAllopathic & Osteopathic PhysiciansGeneral PracticeGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
WA1377100Medicaid
WAAB06893Medicare PIN