Basic Information
| Provider Information | |||||||||
| NPI: | 1801803051 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | COOPER PRIMARY CARE AT PENNSVILLE, PA | ||||||||
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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: | 390 NORTH BROAD STREET | ||||||||
| Address2: | CONCORD PROFESSIONAL BUILDING, STE 100 | ||||||||
| City: | PENNSVILLE | ||||||||
| State: | NJ | ||||||||
| PostalCode: | 08070 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8566786411 | ||||||||
| FaxNumber: | 8566787509 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 08/01/2006 | ||||||||
| 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 | 207R00000X | N | 193400000X MULTIPLE SINGLE SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Internal Medicine | 207R00000X | NJ | Y | 193400000X MULTIPLE SINGLE SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Internal Medicine |
ID Information
| ID | Type | State | Issuer | Description | 15096 | 01 | AETNA | OTHER | 0479412001 | 01 | AMERIHEALTH | OTHER | 7209908 | 05 | NJ | MEDICAID |