Basic Information
| Provider Information | |||||||||
| NPI: | 1902192529 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | COOPER SURGICAL ASSOCIATES, PA | ||||||||
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| Mailing Information | |||||||||
| Address1: | 3 COOPER PLZ | ||||||||
| Address2: | SUITE 502 | ||||||||
| City: | CAMDEN | ||||||||
| State: | NJ | ||||||||
| PostalCode: | 081031438 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8569636888 | ||||||||
| FaxNumber: | 8569688499 | ||||||||
| Practice Location | |||||||||
| Address1: | 3 COOPER PLZ | ||||||||
| Address2: | SUITE 411 | ||||||||
| City: | CAMDEN | ||||||||
| State: | NJ | ||||||||
| PostalCode: | 081031438 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8563422270 | ||||||||
| FaxNumber: | 8563651180 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 06/22/2011 | ||||||||
| LastUpdateDate: | 06/22/2011 | ||||||||
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| AuthorizedOfficialLastName: | BEKES | ||||||||
| AuthorizedOfficialFirstName: | CAROLYN | ||||||||
| AuthorizedOfficialMiddleName: | E | ||||||||
| AuthorizedOfficialTitleorPosition: | CHIEF MEDICAL OFFICER, SEVP | ||||||||
| AuthorizedOfficialTelephone: | 8569636888 | ||||||||
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| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialCredential: | MD | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 208C00000X | Y | 193400000X SINGLE SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Colon & Rectal Surgery |
ID Information
| ID | Type | State | Issuer | Description | 2344458000 | 01 | NJ | AMERIHEALTH GROUP NUMBER | OTHER |