Basic Information
| Provider Information | |||||||||
| NPI: | 1639146939 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | COHEN | ||||||||
| FirstName: | ROGER | ||||||||
| MiddleName: | B | ||||||||
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| Credential: | MD | ||||||||
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| Mailing Information | |||||||||
| Address1: | 3400 CIVIC CENTER BOULEVARD | ||||||||
| Address2: | |||||||||
| City: | PHILADELPHIA | ||||||||
| State: | PA | ||||||||
| PostalCode: | 191045127 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2156155858 | ||||||||
| FaxNumber: | 2153498144 | ||||||||
| Practice Location | |||||||||
| Address1: | 3400 CIVIC CENTER BOULEVARD | ||||||||
| Address2: | |||||||||
| City: | PHILADELPHIA | ||||||||
| State: | PA | ||||||||
| PostalCode: | 191045127 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2156155858 | ||||||||
| FaxNumber: | 2153498144 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 03/06/2006 | ||||||||
| LastUpdateDate: | 10/12/2012 | ||||||||
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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 | 207RX0202X | MD073307L | PA | N | Allopathic & Osteopathic Physicians | Internal Medicine | Medical Oncology | 207RH0003X | MD073307L | PA | Y | Allopathic & Osteopathic Physicians | Internal Medicine | Hematology & Oncology |
ID Information
| ID | Type | State | Issuer | Description | 0018500560001 | 05 | PA | MEDICAID |