Healthcare Provider Details

I. General information

NPI: 1801803051
Provider Name (Legal Business Name): COOPER PRIMARY CARE AT PENNSVILLE, PA
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 08/01/2006
Last Update Date: 07/27/2016
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

390 NORTH BROAD STREET CONCORD PROFESSIONAL BUILDING, STE 100
PENNSVILLE NJ
08070
US

IV. Provider business mailing address

1 FEDERAL STREET SW-200
CAMDEN NJ
08103-1155
US

V. Phone/Fax

Practice location:
  • Phone: 856-678-6411
  • Fax: 856-678-7509
Mailing address:
  • Phone: 856-356-4924
  • Fax: 856-382-6455

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code207R00000X
TaxonomyInternal Medicine Physician
License Number
License Number State
# 2
Primary TaxonomyY
Taxonomy Code207R00000X
TaxonomyInternal Medicine Physician
License Number
License Number StateNJ

VIII. Authorized Official

Name: ANTHONY J. MAZZARELLI
Title or Position: CHIEF MEDICAL OFFICE
Credential: M.D.
Phone: 856-968-7858