=====================================================
General NPI Number Information
=====================================================
NPI Number | 1194922963
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | MARION LESLIE COOPER II M.D.
-----------------------------------------------------
Gender | Male
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 06/27/2007
-----------------------------------------------------
Last Update Date | 01/12/2025
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 5133 RIVERS AVE
-----------------------------------------------------
City | N CHARLESTON
-----------------------------------------------------
State | SC
-----------------------------------------------------
Zip | 29406-6338
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 843-789-1786
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | PO BOX 751649
-----------------------------------------------------
City | CHARLOTTE
-----------------------------------------------------
State | NC
-----------------------------------------------------
Zip | 28275-1649
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 888-472-0043
-----------------------------------------------------
Fax | 843-724-2440
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 207Q00000X
-----------------------------------------------------
Taxonomy Name | Family Medicine Physician
-----------------------------------------------------
License Number | 30037
-----------------------------------------------------
License Number State | SC
-----------------------------------------------------