Provider Demographics
NPI:1154306033
Name:COOPER, GLENN S (MD)
Entity Type:Individual
Prefix:DR
First Name:GLENN
Middle Name:S
Last Name:COOPER
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Gender:M
Credentials:MD
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Mailing Address - Street 1:2422 S BROAD ST
Mailing Address - Street 2:1ST FLOOR
Mailing Address - City:PHILA
Mailing Address - State:PA
Mailing Address - Zip Code:19145-4418
Mailing Address - Country:US
Mailing Address - Phone:215-389-1748
Mailing Address - Fax:215-389-0604
Practice Address - Street 1:2422 S BROAD ST
Practice Address - Street 2:1ST FLOOR
Practice Address - City:PHILA
Practice Address - State:PA
Practice Address - Zip Code:19145-4418
Practice Address - Country:US
Practice Address - Phone:215-389-1748
Practice Address - Fax:215-389-0604
Is Sole Proprietor?:No
Enumeration Date:2005-12-13
Last Update Date:2017-04-19
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Provider Licenses
StateLicense IDTaxonomies
PAMD042074L207RC0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RC0000XAllopathic & Osteopathic PhysiciansInternal MedicineCardiovascular Disease
Provider Identifiers
StateIdentifier IDID TypeIssuer
PA0014735400001Medicaid
PAF81653Medicare UPIN
PA0014735400001Medicaid