Healthcare Provider Details

I. General information

NPI: 1962525485
Provider Name (Legal Business Name): COOPER PEDIATRIC SPECIALIST
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 04/09/2007
Last Update Date: 08/22/2020
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3 COOPER PLZ SUITE 200
CAMDEN NJ
08103-1438
US

IV. Provider business mailing address

3 COOPER PLZ SUITE 502
CAMDEN NJ
08103-1438
US

V. Phone/Fax

Practice location:
  • Phone: 856-342-2001
  • Fax:
Mailing address:
  • Phone: 856-968-7433
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code2080A0000X
TaxonomyPediatric Adolescent Medicine Physician
License Number
License Number State

VII. Legacy identifiers

For crosswalk purposes, the following legacy (non-NPI) identifiers are available for this provider:

# 1
Identifier9024603
Identifier TypeMEDICAID
Identifier StateNJ
Identifier Issuer

VIII. Authorized Official

Name: ROBERT MCMULLEN
Title or Position: EVP MANAGED CARE
Credential:
Phone: 856-342-7369