Provider Demographics
NPI:1467655902
Name:COOPER FAMILY MEDICINE PC
Entity Type:Organization
Organization Name:COOPER FAMILY MEDICINE PC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:EVP MANAGED CARE
Authorized Official - Prefix:
Authorized Official - First Name:ROBERT
Authorized Official - Middle Name:
Authorized Official - Last Name:MCMULLEN
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:856-342-2921
Mailing Address - Street 1:3 COOPER PLZ
Mailing Address - Street 2:SUITE 502
Mailing Address - City:CAMDEN
Mailing Address - State:NJ
Mailing Address - Zip Code:08103-1438
Mailing Address - Country:US
Mailing Address - Phone:856-342-2921
Mailing Address - Fax:856-968-8499
Practice Address - Street 1:1001 LINCOLN DR W STE F
Practice Address - Street 2:
Practice Address - City:MARLTON
Practice Address - State:NJ
Practice Address - Zip Code:08053-1534
Practice Address - Country:US
Practice Address - Phone:856-810-1800
Practice Address - Fax:856-810-1879
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-06-11
Last Update Date:2008-05-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
NJ0790979001OtherAMERIHEALTH GRP#
NJ6558101Medicaid
NJ774784 DDMMedicare PIN