Provider Demographics
NPI:1164690202
Name:EDWARD ROBERT COHEN
Entity Type:Organization
Organization Name:EDWARD ROBERT COHEN
Other - Org Name:DR EDWARD ROBERT COHEN
Other - Org Type:Doing Business As
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:EDWARD
Authorized Official - Middle Name:ROBERT
Authorized Official - Last Name:COHEN
Authorized Official - Suffix:
Authorized Official - Credentials:DPM
Authorized Official - Phone:228-832-4475
Mailing Address - Street 1:12056 MOBILE AVE
Mailing Address - Street 2:
Mailing Address - City:GULFPORT
Mailing Address - State:MS
Mailing Address - Zip Code:39503
Mailing Address - Country:US
Mailing Address - Phone:228-832-4475
Mailing Address - Fax:228-832-1512
Practice Address - Street 1:905 B HARDY ST
Practice Address - Street 2:
Practice Address - City:HATTIESBURG
Practice Address - State:MS
Practice Address - Zip Code:39401-4162
Practice Address - Country:US
Practice Address - Phone:601-582-7673
Practice Address - Fax:601-545-2824
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-02-12
Last Update Date:2008-04-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MS80055332B00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes332B00000XSuppliersDurable Medical Equipment & Medical Supplies
Provider Identifiers
StateIdentifier IDID TypeIssuer
MS01504061Medicaid
MS0657170005Medicare NSC