Provider Demographics
NPI:1790775658
Name:COHEN, JACK B (MD)
Entity Type:Individual
Prefix:
First Name:JACK
Middle Name:B
Last Name:COHEN
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Gender:M
Credentials:MD
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Mailing Address - Street 1:101 E OLNEY AVE
Mailing Address - Street 2:STE 400
Mailing Address - City:PHILADELPHIA
Mailing Address - State:PA
Mailing Address - Zip Code:19120-2470
Mailing Address - Country:US
Mailing Address - Phone:215-456-1825
Mailing Address - Fax:215-456-5926
Practice Address - Street 1:BROAD AND VINE STS
Practice Address - Street 2:MS 310
Practice Address - City:PHILA
Practice Address - State:PA
Practice Address - Zip Code:19102
Practice Address - Country:US
Practice Address - Phone:215-762-4312
Practice Address - Fax:215-762-8656
Is Sole Proprietor?:No
Enumeration Date:2005-10-24
Last Update Date:2020-02-13
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Provider Licenses
StateLicense IDTaxonomies
PAMD055971L207L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207L00000XAllopathic & Osteopathic PhysiciansAnesthesiology
Provider Identifiers
StateIdentifier IDID TypeIssuer
PA813186Medicare ID - Type Unspecified
G18467Medicare UPIN