Provider Demographics
NPI:1013070580
Name:COOPER, SALLY A (MD)
Entity type:Individual
Prefix:
First Name:SALLY
Middle Name:A
Last Name:COOPER
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Credentials:
Mailing Address - Street 1:78 ATLANTIC PL
Mailing Address - Street 2:
Mailing Address - City:SOUTH PORTLAND
Mailing Address - State:ME
Mailing Address - Zip Code:04106-2316
Mailing Address - Country:US
Mailing Address - Phone:207-661-6654
Mailing Address - Fax:207-842-7773
Practice Address - Street 1:123 ANDOVER RD
Practice Address - Street 2:
Practice Address - City:WESTBROOK
Practice Address - State:ME
Practice Address - Zip Code:04092-3848
Practice Address - Country:US
Practice Address - Phone:207-761-2200
Practice Address - Fax:207-761-2108
Is Sole Proprietor?:No
Enumeration Date:2006-12-18
Last Update Date:2016-10-03
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
MEMD140992084P0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2084P0800XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyPsychiatry
Provider Identifiers
StateIdentifier IDID TypeIssuer
ME1013070580Medicaid
ME104540000Medicaid
000373103Medicare PIN
ME001363701Medicare PIN
MEE400216765Medicare PIN
ME000373101Medicare PIN