Basic Information
Provider Information | |||||||||
NPI: | 1649463696 | ||||||||
EntityType: | 2 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: | COOPER SURGICAL ASSCOCIATES | ||||||||
LastName: |   | ||||||||
FirstName: |   | ||||||||
MiddleName: |   | ||||||||
NamePrefix: |   | ||||||||
NameSuffix: |   | ||||||||
Credential: |   | ||||||||
OtherOrganizationName: |   | ||||||||
OtherOrganizationType: |   | ||||||||
OtherLastName: |   | ||||||||
OtherFirstName: |   | ||||||||
OtherMiddleName: |   | ||||||||
OtherNamePrefix: |   | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: |   | ||||||||
OtherLastNameType: |   | ||||||||
Mailing Information | |||||||||
Address1: | 3 COOPER PLZ | ||||||||
Address2: | SUTIE 502 | ||||||||
City: | CAMDEN | ||||||||
State: | NJ | ||||||||
PostalCode: | 081031438 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 8569687433 | ||||||||
FaxNumber: |   | ||||||||
Practice Location | |||||||||
Address1: | 3 COOPER PLZ | ||||||||
Address2: | SUITE 411 | ||||||||
City: | CAMDEN | ||||||||
State: | NJ | ||||||||
PostalCode: | 081031438 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 8563423250 | ||||||||
FaxNumber: |   | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 08/23/2007 | ||||||||
LastUpdateDate: | 08/23/2007 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: |   | ||||||||
AuthorizedOfficialLastName: | MCMULLEN | ||||||||
AuthorizedOfficialFirstName: | ROBERT | ||||||||
AuthorizedOfficialMiddleName: |   | ||||||||
AuthorizedOfficialTitleorPosition: | EVP - MANAGED CARE | ||||||||
AuthorizedOfficialTelephone: | 8569687263 | ||||||||
IsSoleProprietor: |   | ||||||||
IsOrganizationSubpart: | Y | ||||||||
ParentOrganizationLBN: | COOPER SURGICAL ASSCOCIATES | ||||||||
AuthorizedOfficialNamePrefix: |   | ||||||||
AuthorizedOfficialNameSuffix: |   | ||||||||
AuthorizedOfficialCredential: |   | ||||||||
NPICertificationDate: |   |
Taxonomy Information
Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 2086S0120X |   |   | Y | 193400000X SINGLE SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Surgery | Pediatric Surgery |
ID Information
ID | Type | State | Issuer | Description | 2865807 | 05 | NJ |   | MEDICAID | 2843948000 | 01 | NJ | AMERIHEALTH/KEYSTONE/IBC | OTHER |