Provider Demographics
NPI:1881996130
Name:COOPER MEDICAL GROUP PC
Entity type:Organization
Organization Name:COOPER MEDICAL GROUP PC
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:OWNER / PHYSICIAN
Authorized Official - Prefix:DR
Authorized Official - First Name:KEITH
Authorized Official - Middle Name:EUGENE
Authorized Official - Last Name:COOPER
Authorized Official - Suffix:
Authorized Official - Credentials:DO
Authorized Official - Phone:812-476-4161
Mailing Address - Street 1:1401 S GREEN RIVER RD
Mailing Address - Street 2:
Mailing Address - City:EVANSVILLE
Mailing Address - State:IN
Mailing Address - Zip Code:47715-5657
Mailing Address - Country:US
Mailing Address - Phone:812-476-4161
Mailing Address - Fax:812-476-4178
Practice Address - Street 1:1401 S GREEN RIVER RD
Practice Address - Street 2:
Practice Address - City:EVANSVILLE
Practice Address - State:IN
Practice Address - Zip Code:47715-5657
Practice Address - Country:US
Practice Address - Phone:812-476-4161
Practice Address - Fax:812-476-4178
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2010-11-18
Last Update Date:2010-12-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN02002249A207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Single Specialty