Basic Information
| Provider Information | |||||||||
| NPI: | 1568646818 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | COOLEY | ||||||||
| FirstName: | ROGER | ||||||||
| MiddleName: | SCOTT | ||||||||
| NamePrefix: | DR. | ||||||||
| NameSuffix: | |||||||||
| Credential: | M.D. | ||||||||
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| Mailing Information | |||||||||
| Address1: | 3998 FAIR RIDGE DR | ||||||||
| Address2: | SUITE 300 | ||||||||
| City: | FAIRFAX | ||||||||
| State: | VA | ||||||||
| PostalCode: | 220332921 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7032959360 | ||||||||
| FaxNumber: | 7037669725 | ||||||||
| Practice Location | |||||||||
| Address1: | 500 J CLYDE MORRIS BLVD | ||||||||
| Address2: | |||||||||
| City: | NEWPORT NEWS | ||||||||
| State: | VA | ||||||||
| PostalCode: | 236011929 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7575942000 | ||||||||
| FaxNumber: | 7578269028 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 12/21/2007 | ||||||||
| LastUpdateDate: | 03/27/2015 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 122300000X | 30.016732 | OH | N | Dental Providers | Dentist | 207L00000X | 35091962 | OH | N | Allopathic & Osteopathic Physicians | Anesthesiology | 207L00000X | 0101253918 | VA | Y | Allopathic & Osteopathic Physicians | Anesthesiology |
ID Information
| ID | Type | State | Issuer | Description | 2880888 | 05 | OH | MEDICAID | CO4245341 | 01 | OH | MEDICARE | OTHER | 1568646818 | 05 | VA | MEDICAID |