Provider Demographics
NPI:1972568244
Name:COOPERMAN, MICHAEL T (MD)
Entity type:Individual
Prefix:
First Name:MICHAEL
Middle Name:T
Last Name:COOPERMAN
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
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Mailing Address - Street 1:25 WASHINGTON LN
Mailing Address - Street 2:STE 22C
Mailing Address - City:WYNCOTE
Mailing Address - State:PA
Mailing Address - Zip Code:19095-1425
Mailing Address - Country:US
Mailing Address - Phone:215-635-4902
Mailing Address - Fax:215-635-2565
Practice Address - Street 1:921 WEST CHELTENHAM AVE
Practice Address - Street 2:
Practice Address - City:MELROSE PARK
Practice Address - State:PA
Practice Address - Zip Code:19027
Practice Address - Country:US
Practice Address - Phone:215-635-4902
Practice Address - Fax:215-635-2565
Is Sole Proprietor?:Not Answered
Enumeration Date:2006-04-19
Last Update Date:2019-07-15
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
PAMD017737E207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
PA1629552Medicaid
37280OtherAETNA
00544020001OtherKEYSTONE HPE
8864099004OtherCIGNA
1025978OtherKEYSTONE MERCY
00544020001OtherKEYSTONE HPE
37280OtherAETNA