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	207K00000X	Allergy & Immunology Physician	MC-0254	AR

General Provider Information

NPI Number	:	1811013428
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	:	9101 JENNY LIND RD
Second Line	:
City	:	FORT SMITH
State	:	AR
Zip	:	72908-9142
Country	:	US
Telephone Number	:	479-274-5600
Fax Number	:	479-646-6069

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

Provider Enumeration Date	:	03/22/2007
Last Update Date	:	09/01/2015

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