1275701310 NPI number — EDWARD ROBERT COHEN

Table of content: (NPI 1275701310)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1275701310 NPI number — EDWARD ROBERT COHEN

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
EDWARD ROBERT COHEN
Provider Last Name:
Provider First Name:
Provider Middle Name:
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
Provider Gender Code:

Provider's Other Name Information

Provider Other Organization Name:
DR EDWARD ROBERT COHEN
Provider Other Organization Name Type Code:
3
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1275701310
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
04/18/2008
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
12056 MOBILE AVE
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
GULFPORT
Provider Business Mailing Address State Name:
MS
Provider Business Mailing Address Postal Code:
39503-3004
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
228-832-4475
Provider Business Mailing Address Fax Number:
228-832-1512

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
7530 HIGHWAY 57
Provider Second Line Business Practice Location Address:
STE A
Provider Business Practice Location Address City Name:
OCEAN SPRINGS
Provider Business Practice Location Address State Name:
MS
Provider Business Practice Location Address Postal Code:
39565-6512
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
228-872-4900
Provider Business Practice Location Address Fax Number:
228-872-0803
Provider Enumeration Date:
02/12/2008

Additional Information

Authorized Official

Authorized Official Last Name:
COHEN
Authorized Official First Name:
EDWARD
Authorized Official Middle Name:
ROBERT
Authorized Official Title or Position:
OWNER
Authorized Official Telephone Number:
228-832-4475

Provider Taxonomy Codes

  • Taxonomy code: 332B00000X , with the licence number:  80055 , registered in the state of MS ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)

  • Identifier: 06621244 , issued by the state of ( MS ) . This identifiers is of the category "MEDICAID".




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