Basic Information
| Provider Information | |||||||||
| NPI: | 1649217175 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | COOPER FAMILY MEDICINE, PC | ||||||||
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| Mailing Information | |||||||||
| Address1: | 1 FEDERAL STREET | ||||||||
| Address2: | SW-200 | ||||||||
| City: | CAMDEN | ||||||||
| State: | NJ | ||||||||
| PostalCode: | 081031155 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8563564924 | ||||||||
| FaxNumber: | 8563826455 | ||||||||
| Practice Location | |||||||||
| Address1: | 1050 KINGS HWY N | ||||||||
| Address2: | SUITE 105 | ||||||||
| City: | CHERRY HILL | ||||||||
| State: | NJ | ||||||||
| PostalCode: | 080341909 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8563210303 | ||||||||
| FaxNumber: | 8563210090 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 06/01/2006 | ||||||||
| LastUpdateDate: | 07/27/2016 | ||||||||
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| AuthorizedOfficialLastName: | MAZZARELLI | ||||||||
| AuthorizedOfficialFirstName: | ANTHONY | ||||||||
| AuthorizedOfficialMiddleName: | J. | ||||||||
| AuthorizedOfficialTitleorPosition: | CHIEF MEDICAL OFFICE | ||||||||
| AuthorizedOfficialTelephone: | 8569687858 | ||||||||
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| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialCredential: | M.D. | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207Q00000X | N | 193400000X MULTIPLE SINGLE SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Family Medicine | 207Q00000X | NJ | Y | 193400000X MULTIPLE SINGLE SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Family Medicine |
ID Information
| ID | Type | State | Issuer | Description | 6558101 | 05 | NJ | MEDICAID | 812711 | 01 | AETNA | OTHER | 957013 | 01 | AETNA | OTHER | 0341834001 | 01 | AMERIHEALTH | OTHER | 10825 | 01 | AETNA | OTHER | 0538689001 | 01 | AMERIHEALTH | OTHER | 0790979001 | 01 | AMERIHEALTH | OTHER | 10678 | 01 | AETNA | OTHER | 0807068001 | 01 | AMERIHEALTH | OTHER | 0125591001 | 01 | AMERIHEALTH | OTHER | 0807062001 | 01 | AMERIHEALTH | OTHER | 10665 | 01 | AETNA | OTHER | 2218882006 | 01 | AMERIHEALTH | OTHER | 497006 | 01 | AETNA | OTHER | 511584 | 01 | AETNA | OTHER | 0807066001 | 01 | AMERIHEALTH | OTHER | 10453 | 01 | AETNA | OTHER |