MEDICARE: JACK B COHEN MD

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	207L00000X	Anesthesiology Physician	MD055971L	PA

General Provider Information

NPI Number	:	1790775658
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	JACK B COHEN MD

Provider Business Mailing Address
First Line	:	101 E OLNEY AVE
Second Line	:	STE 400
City	:	PHILADELPHIA
State	:	PA
Zip	:	19120-2470
Country	:	US
Telephone Number	:	215-456-1825
Fax Number	:	215-456-5926

Provider Business Practice Location Address
First Line	:	BROAD AND VINE STS
Second Line	:	MS 310
City	:	PHILA
State	:	PA
Zip	:	19102
Country	:	US
Telephone Number	:	215-762-4312
Fax Number	:	215-762-8656

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	10/24/2005
Last Update Date	:	02/13/2020

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