Provider Demographics
NPI:1295808590
Name:ENT & FACIAL PLASTIC SURGERY, P.A.
Entity type:Organization
Organization Name:ENT & FACIAL PLASTIC SURGERY, P.A.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:STEPHEN
Authorized Official - Middle Name:G
Authorized Official - Last Name:COOPER
Authorized Official - Suffix:
Authorized Official - Credentials:MD,
Authorized Official - Phone:302-674-3752
Mailing Address - Street 1:826 S GOVERNORS AVE
Mailing Address - Street 2:
Mailing Address - City:DOVER
Mailing Address - State:DE
Mailing Address - Zip Code:19904-4107
Mailing Address - Country:US
Mailing Address - Phone:302-674-3752
Mailing Address - Fax:302-674-8521
Practice Address - Street 1:826 S GOVERNORS AVE
Practice Address - Street 2:
Practice Address - City:DOVER
Practice Address - State:DE
Practice Address - Zip Code:19904-4107
Practice Address - Country:US
Practice Address - Phone:302-674-3752
Practice Address - Fax:302-674-8521
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-11-16
Last Update Date:2008-08-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
DEC10002552207YX0905X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207YX0905XAllopathic & Osteopathic PhysiciansOtolaryngologyOtolaryngology/Facial Plastic SurgeryGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
DE000221602Medicaid
DE055612Medicare ID - Type Unspecified
DE000221602Medicaid