1770800955 NPI number — DM COOPER, DPM & ASSOCIATES, DPM

Table of content: (NPI 1770800955)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1770800955 NPI number — DM COOPER, DPM & ASSOCIATES, DPM

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
DM COOPER, DPM & ASSOCIATES, DPM
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:
Provider Other Organization Name Type Code:
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:
1770800955
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
04/27/2010
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
8603 GILBERT ST
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
PHILADELPHIA
Provider Business Mailing Address State Name:
PA
Provider Business Mailing Address Postal Code:
19150-2703
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
267-972-9992
Provider Business Mailing Address Fax Number:
267-385-5022

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
2621 W 9TH ST
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
CHESTER
Provider Business Practice Location Address State Name:
PA
Provider Business Practice Location Address Postal Code:
19013-2115
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
267-972-9992
Provider Business Practice Location Address Fax Number:
267-385-5022
Provider Enumeration Date:
04/27/2010

Additional Information

Authorized Official

Authorized Official Last Name:
COOPER
Authorized Official First Name:
DIREESE
Authorized Official Middle Name:
MARY
Authorized Official Title or Position:
PODIATRIST
Authorized Official Telephone Number:
267-972-9992

Provider Taxonomy Codes

  • Taxonomy code: 213EP1101X , with the licence number:  SC003585R , registered in the state of PA ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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

  • Identifier: 001232500000 , issued by the state of ( PA ) . This identifiers is of the category "MEDICAID".




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