=====================================================
General NPI Number Information
=====================================================
NPI Number | 1770876229
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | CHAD JOSEPH COOPER M.D.
-----------------------------------------------------
Gender | Male
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 05/17/2011
-----------------------------------------------------
Last Update Date | 09/29/2021
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 1441 WILKINS CIR
-----------------------------------------------------
City | CASPER
-----------------------------------------------------
State | WY
-----------------------------------------------------
Zip | 82601-1337
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 307-233-2700
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 1441 WILKINS CIR
-----------------------------------------------------
City | CASPER
-----------------------------------------------------
State | WY
-----------------------------------------------------
Zip | 82601-1337
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 307-233-2700
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 207RG0100X
-----------------------------------------------------
Taxonomy Name | Gastroenterology Physician
-----------------------------------------------------
License Number | 48391
-----------------------------------------------------
License Number State | KY
-----------------------------------------------------
Taxonomy #2
-----------------------------------------------------
Taxonomy Code | 207RG0100X
-----------------------------------------------------
Taxonomy Name | Gastroenterology Physician
-----------------------------------------------------
License Number | 12103A
-----------------------------------------------------
License Number State | WY
-----------------------------------------------------