Provider Demographics
NPI:1801803051
Name:COOPER PRIMARY CARE AT PENNSVILLE, PA
Entity type:Organization
Organization Name:COOPER PRIMARY CARE AT PENNSVILLE, PA
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CHIEF MEDICAL OFFICE
Authorized Official - Prefix:
Authorized Official - First Name:ANTHONY
Authorized Official - Middle Name:J
Authorized Official - Last Name:MAZZARELLI
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:856-968-7858
Mailing Address - Street 1:1 FEDERAL STREET
Mailing Address - Street 2:SW-200
Mailing Address - City:CAMDEN
Mailing Address - State:NJ
Mailing Address - Zip Code:08103-1155
Mailing Address - Country:US
Mailing Address - Phone:856-356-4924
Mailing Address - Fax:856-382-6455
Practice Address - Street 1:390 NORTH BROAD STREET
Practice Address - Street 2:CONCORD PROFESSIONAL BUILDING, STE 100
Practice Address - City:PENNSVILLE
Practice Address - State:NJ
Practice Address - Zip Code:08070
Practice Address - Country:US
Practice Address - Phone:856-678-6411
Practice Address - Fax:856-678-7509
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-08-01
Last Update Date:2016-07-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
207R00000X
NJ207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal MedicineGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
15096OtherAETNA
0479412001OtherAMERIHEALTH
NJ7209908Medicaid
NJCE7308Medicare PIN
NJ7209908Medicaid
0479412001OtherAMERIHEALTH