Basic Information
| Provider Information | |||||||||
| NPI: | 1770616153 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | COOPER PEDIATRIC SPECIALIST | ||||||||
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| Mailing Information | |||||||||
| Address1: | 3 COOPER PLZ | ||||||||
| Address2: | SUITE 502 | ||||||||
| City: | CAMDEN | ||||||||
| State: | NJ | ||||||||
| PostalCode: | 081031438 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8569687433 | ||||||||
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| Address1: | 3 COOPER PLZ | ||||||||
| Address2: | SUITE 200 | ||||||||
| City: | CAMDEN | ||||||||
| State: | NJ | ||||||||
| PostalCode: | 081031438 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8563422000 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 03/14/2007 | ||||||||
| LastUpdateDate: | 08/22/2020 | ||||||||
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| AuthorizedOfficialLastName: | MCMULLEN | ||||||||
| AuthorizedOfficialFirstName: | ROBERT | ||||||||
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| AuthorizedOfficialTitleorPosition: | EVP MANAGED CARE | ||||||||
| AuthorizedOfficialTelephone: | 8563427263 | ||||||||
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| IsOrganizationSubpart: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 2080P0214X | Y | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Pediatrics | Pediatric Pulmonology |
ID Information
| ID | Type | State | Issuer | Description | 2125254000 | 01 | AMERIHEALTH GRP NUMBER | OTHER | 9024603 | 05 | NJ | MEDICAID |