Healthcare Provider Details

I. General information

NPI: 1629073978
Provider Name (Legal Business Name): BRENDA GAIL COOPER MD
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/14/2005
Last Update Date: 08/16/2010
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

6501 PEAKE RD STE 900
MACON GA
31210-8051
US

IV. Provider business mailing address

6501 PEAKE RD STE 900
MACON GA
31210-8051
US

V. Phone/Fax

Practice location:
  • Phone: 478-471-9047
  • Fax: 478-757-1088
Mailing address:
  • Phone: 478-471-9047
  • Fax: 478-757-1088

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207RG0100X
TaxonomyGastroenterology Physician
License Number038453
License Number StateGA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: