Healthcare Provider Details

I. General information

NPI: 1518175215
Provider Name (Legal Business Name): COOLEY NEUROSURGICAL CLINIC INC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 05/18/2007
Last Update Date: 08/22/2020
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

830 W HIGH ST SUITE 204
LIMA OH
45801-3971
US

IV. Provider business mailing address

PO BOX 1216
LIMA OH
45802-1216
US

V. Phone/Fax

Practice location:
  • Phone: 419-229-8928
  • Fax: 419-229-5291
Mailing address:
  • Phone: 419-229-8928
  • Fax: 419-229-5291

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207T00000X
TaxonomyNeurological Surgery Physician
License Number35049465
License Number StateOH

VII. Legacy identifiers

For crosswalk purposes, the following legacy (non-NPI) identifiers are available for this provider:

# 1
Identifier000000167548
Identifier TypeOTHER
Identifier StateOH
Identifier IssuerANTHEM
# 2
Identifier0859441
Identifier TypeMEDICAID
Identifier StateOH
Identifier Issuer

VIII. Authorized Official

Name: DR. DAVID A COOLEY
Title or Position: PRESIDENT
Credential: M.D.
Phone: 419-229-8928