Provider Demographics
NPI:1871636720
Name:COPPS MEDICAL PC
Entity Type:Organization
Organization Name:COPPS MEDICAL PC
Other - Org Name:CEDARS OCCUPATIONAL PHYSICAL PAIN AND SPINE MEDICAL PC
Other - Org Type:Other Name
Authorized Official - Title/Position:OFFICE MANAGER
Authorized Official - Prefix:
Authorized Official - First Name:JOSEPH
Authorized Official - Middle Name:P
Authorized Official - Last Name:KALYOUSSEF
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:315-797-1340
Mailing Address - Street 1:100 GENESEE ST
Mailing Address - Street 2:
Mailing Address - City:NEW HARTFORD
Mailing Address - State:NY
Mailing Address - Zip Code:13413-2328
Mailing Address - Country:US
Mailing Address - Phone:315-797-1340
Mailing Address - Fax:315-797-2403
Practice Address - Street 1:100 GENESEE ST
Practice Address - Street 2:
Practice Address - City:NEW HARTFORD
Practice Address - State:NY
Practice Address - Zip Code:13413-2328
Practice Address - Country:US
Practice Address - Phone:315-797-1340
Practice Address - Fax:315-797-2403
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-02-14
Last Update Date:2012-02-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY1769442081P2900X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes2081P2900XAllopathic & Osteopathic PhysiciansPhysical Medicine & RehabilitationPain MedicineGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
NYBA1456Medicare PIN