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	207Q00000X	Family Medicine Physician	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	:	1366655623
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	:	1801 E MAIN ST
Second Line	:
City	:	CHARLESTON
State	:	AR
Zip	:	72933-9254
Country	:	US
Telephone Number	:	479-274-2000
Fax Number	:	479-274-2194

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

Provider Enumeration Date	:	05/07/2007
Last Update Date	:	10/20/2015

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Directions to “COOPER CLINIC PA ” Practice Location

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