Provider Demographics
NPI:1972704153
Name:GROVE PODIATRY ASSOCIATION INC
Entity Type:Organization
Organization Name:GROVE PODIATRY ASSOCIATION INC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:RICHARD
Authorized Official - Middle Name:W
Authorized Official - Last Name:COOPERMAN
Authorized Official - Suffix:
Authorized Official - Credentials:DPM
Authorized Official - Phone:856-299-1064
Mailing Address - Street 1:291 HARDING HWY
Mailing Address - Street 2:SUITE 2
Mailing Address - City:CARNEYS POINT
Mailing Address - State:NJ
Mailing Address - Zip Code:08069-2229
Mailing Address - Country:US
Mailing Address - Phone:856-299-1064
Mailing Address - Fax:856-299-2375
Practice Address - Street 1:291 HARDING HWY
Practice Address - Street 2:SUITE 2
Practice Address - City:CARNEYS POINT
Practice Address - State:NJ
Practice Address - Zip Code:08069-2229
Practice Address - Country:US
Practice Address - Phone:856-299-1064
Practice Address - Fax:856-299-2375
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-05-29
Last Update Date:2013-05-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJ25MD00138600213ES0131X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes213ES0131XPodiatric Medicine & Surgery Service ProvidersPodiatristFoot SurgeryGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
NJU01981Medicare UPIN
NJ185040Medicare PIN
NJ085553Medicare ID - Type Unspecified