Healthcare Provider Details

I. General information

NPI: 1255511572
Provider Name (Legal Business Name): JACK MARSHALL COOPER MD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 11/05/2007
Last Update Date: 01/05/2023
Certification Date: 01/05/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

470 TAYLOR RD SUITE 202
MONTGOMERY AL
36117-3563
US

IV. Provider business mailing address

301 BROWN SPRINGS RD
MONTGOMERY AL
36117-7005
US

V. Phone/Fax

Practice location:
  • Phone: 334-244-6773
  • Fax: 334-244-4234
Mailing address:
  • Phone: 334-747-4159
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code208600000X
TaxonomySurgery Physician
License Number2012-00248
License Number StateNC
# 2
Primary TaxonomyY
Taxonomy Code208600000X
TaxonomySurgery Physician
License Number32228
License Number StateAL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: