Healthcare Provider Details

I. General information

NPI: 1972704153
Provider Name (Legal Business Name): GROVE PODIATRY ASSOCIATION INC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 05/29/2007
Last Update Date: 05/23/2013
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

291 HARDING HWY SUITE 2
CARNEYS POINT NJ
08069-2229
US

IV. Provider business mailing address

291 HARDING HWY SUITE 2
CARNEYS POINT NJ
08069-2229
US

V. Phone/Fax

Practice location:
  • Phone: 856-299-1064
  • Fax: 856-299-2375
Mailing address:
  • Phone: 856-299-1064
  • Fax: 856-299-2375

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code213ES0131X
TaxonomyFoot Surgery Podiatrist
License Number25MD00138600
License Number StateNJ

VIII. Authorized Official

Name: RICHARD W COOPERMAN
Title or Position: PRESIDENT
Credential: DPM
Phone: 856-299-1064