Provider Demographics
NPI:1518187392
Name:PENNSUAKEN FAMILY PRACTICE, PC
Entity Type:Organization
Organization Name:PENNSUAKEN FAMILY PRACTICE, PC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:HERMAN
Authorized Official - Middle Name:P
Authorized Official - Last Name:COHEN
Authorized Official - Suffix:
Authorized Official - Credentials:DO
Authorized Official - Phone:856-663-1470
Mailing Address - Street 1:5647 WESTFIELD AVE
Mailing Address - Street 2:
Mailing Address - City:PENNSAUKEN
Mailing Address - State:NJ
Mailing Address - Zip Code:08110-1836
Mailing Address - Country:US
Mailing Address - Phone:856-663-1470
Mailing Address - Fax:856-663-3409
Practice Address - Street 1:5647 WESTFIELD AVE
Practice Address - Street 2:
Practice Address - City:PENNSAUKEN
Practice Address - State:NJ
Practice Address - Zip Code:08110-1836
Practice Address - Country:US
Practice Address - Phone:856-663-1470
Practice Address - Fax:856-663-3409
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-04-26
Last Update Date:2013-05-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJ61259208D00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes208D00000XAllopathic & Osteopathic PhysiciansGeneral PracticeGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
PA0964523000OtherKEYSTONE
PA3370OtherAETNA
NJ857996Medicaid
NJG25200Medicare UPIN
NJ6897207Medicare ID - Type Unspecified