Healthcare Provider Details

I. General information

NPI: 1407241177
Provider Name (Legal Business Name): AMYLOUISE COOPER CASE
Entity Type: Individual
Gender: Female
Sole Proprietor: N

Provider Other Name: AMY CASE MD

II. Dates (important events)

Enumeration Date: 03/31/2015
Last Update Date: 10/23/2020
Certification Date: 10/22/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

18TH MEDICAL GROUP UNIT 5142
APO AP
96368
US

IV. Provider business mailing address

PSC 80 BOX 22488
APO AP
96367-0109
US

V. Phone/Fax

Practice location:
  • Phone: 315-630-4542
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code208000000X
TaxonomyPediatrics Physician
License Number277079
License Number StateMA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: