Healthcare Provider Details

I. General information

NPI: 1861686453
Provider Name (Legal Business Name): MR. ORRIN ANTON COOPER
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 08/28/2007
Last Update Date: 08/28/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

7505 ELMWOOD AVE
PHILADELPHIA PA
19153-1312
US

IV. Provider business mailing address

7505 ELMWOOD AVE
PHILADELPHIA PA
19153-1312
US

V. Phone/Fax

Practice location:
  • Phone: 215-365-7414
  • Fax: 215-365-7414
Mailing address:
  • Phone: 215-365-7414
  • Fax: 215-365-7414

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code172A00000X
TaxonomyDriver
License Number23533443
License Number StatePA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: