1972568244 NPI number — MICHAEL T COOPERMAN MD

Table of content: MICHAEL T COOPERMAN MD (NPI 1972568244)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1972568244 NPI number — MICHAEL T COOPERMAN MD

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
COOPERMAN
Provider First Name:
MICHAEL
Provider Middle Name:
T
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
MD
Provider Gender Code:
M

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:
1972568244
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
07/15/2019
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
25 WASHINGTON LN
Provider Second Line Business Mailing Address:
STE 22C
Provider Business Mailing Address City Name:
WYNCOTE
Provider Business Mailing Address State Name:
PA
Provider Business Mailing Address Postal Code:
19095-1425
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
215-635-4902
Provider Business Mailing Address Fax Number:
215-635-2565

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
921 WEST CHELTENHAM AVE
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
MELROSE PARK
Provider Business Practice Location Address State Name:
PA
Provider Business Practice Location Address Postal Code:
19027
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
215-635-4902
Provider Business Practice Location Address Fax Number:
215-635-2565
Provider Enumeration Date:
04/19/2006

Additional Information

			
		

Authorized Official

Authorized Official Last Name:
Authorized Official First Name:
Authorized Official Middle Name:
Authorized Official Title or Position:
Authorized Official Telephone Number:

Provider Taxonomy Codes

  • Taxonomy code: 207R00000X , with the licence number:  MD017737E , 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: 1629552 , issued by the state of ( PA ) . This identifiers is of the category "MEDICAID".
  • Identifier: 37280 . This is a "AETNA" identifier . This identifiers is of the category "OTHER".
  • Identifier: 00544020001 . This is a "KEYSTONE HPE" identifier . This identifiers is of the category "OTHER".
  • Identifier: 8864099004 . This is a "CIGNA" identifier . This identifiers is of the category "OTHER".
  • Identifier: 1025978 . This is a "KEYSTONE MERCY" identifier . This identifiers is of the category "OTHER".