Basic Information
| Provider Information | |||||||||
| NPI: | 1720023583 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | COOPER PATHOLOGY, 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: | 1 COOPER PLZ | ||||||||
| Address2: | |||||||||
| City: | CAMDEN | ||||||||
| State: | NJ | ||||||||
| PostalCode: | 081031461 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8563422506 | ||||||||
| FaxNumber: | 8569688806 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 06/17/2006 | ||||||||
| LastUpdateDate: | 07/28/2016 | ||||||||
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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 | 291U00000X | N | Laboratories | Clinical Medical Laboratory | 207ZP0105X | N | 193400000X MULTIPLE SINGLE SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Pathology | Clinical Pathology/Laboratory Medicine | 207ZP0105X | NJ | Y | 193400000X MULTIPLE SINGLE SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Pathology | Clinical Pathology/Laboratory Medicine |
ID Information
| ID | Type | State | Issuer | Description | 0467269000 | 01 | AMERIHEALTH | OTHER | 3452808 | 05 | NJ | MEDICAID | CE0018 | 01 | NJ | RR MEDICARE | OTHER | 88995 | 01 | AETNA | OTHER |