MEDICARE: COOPER CLINIC, PA

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	261Q00000X	Clinic/Center	MC-0254	AR

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program

General Provider Information

NPI Number	:	1104832708
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	COOPER CLINIC, PA

Provider Business Mailing Address
First Line	:	PO BOX 3528
Second Line	:
City	:	FORT SMITH
State	:	AR
Zip	:	72913-3528
Country	:	US
Telephone Number	:	479-274-2000
Fax Number	:	479-274-2194

Provider Business Practice Location Address
First Line	:	4600 TOWSON AVE
Second Line	:	STE 101-N
City	:	FORT SMITH
State	:	AR
Zip	:	72901-7961
Country	:	US
Telephone Number	:	479-274-6900
Fax Number	:	479-648-3951

Authorized Official
Title or Position	:	CEO
Name	:	CURTIS D RALSTON
Credential	:
Telephone Number	:	479-274-2000

Provider Enumeration Date	:	08/01/2006
Last Update Date	:	09/01/2015

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