1104836733 NPI number — KENNETH ROBERT COOKE MD

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1104836733 NPI number — KENNETH ROBERT COOKE MD

Employer Identification Number (EIN):

Provider Organization Name:

Provider Last Name:

COOKE

Provider First Name:

KENNETH

Provider Middle Name:

ROBERT

Provider Name Prefix Text:

Provider Name Suffix Text:

Provider Credential Text:

MD

Provider Gender Code:

M

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:

1104836733

Entity Type Code:

Individual

Replacement NPI:

Last Update Date:

04/04/2023

NPI Deactivation Reason Code:

NPI Deactivation Date:

NPI Reactivation Date:

Provider First Line Business Mailing Address:

6201 GREENLEIGH AVE

Provider Second Line Business Mailing Address:

Provider Business Mailing Address City Name:

BALTIMORE

Provider Business Mailing Address State Name:

MD

Provider Business Mailing Address Postal Code:

21220-2004

Provider Business Mailing Address Country Code:

US

Provider Business Mailing Address Telephone Number:

Provider Business Mailing Address Fax Number:

Provider First Line Business Practice Location Address:

CRB1 RM 207

Provider Second Line Business Practice Location Address:

1650 ORLEANS STREET,

Provider Business Practice Location Address City Name:

BALTIMORE

Provider Business Practice Location Address State Name:

MD

Provider Business Practice Location Address Postal Code:

21287-0001

Provider Business Practice Location Address Country Code:

US

Provider Business Practice Location Address Telephone Number:

443-287-2949

Provider Business Practice Location Address Fax Number:

410-502-7223

Provider Enumeration Date:

08/08/2006

Authorized Official Last Name:

Authorized Official First Name:

Authorized Official Middle Name:

Authorized Official Title or Position:

Authorized Official Telephone Number:

• Taxonomy code: 208000000X , with the licence number:  4301074004 , registered in the state of MI ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
• Taxonomy code: 2080P0207X , with the licence number: 4301074004 , registered in the state of MI ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
• Taxonomy code: 2080P0207X , with the licence number: 35090984 , registered in the state of OH ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
• Taxonomy code: 2080P0207X , with the licence number: D76204 , registered in the state of MD ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

• Identifier: 000000233275 . This is a "UNISON" identifier , issued by the state of ( OH ) . This identifiers is of the category "OTHER".
• Identifier: 4173898 , issued by the state of ( MI ) . This identifiers is of the category "MEDICAID".
• Identifier: 5752459 . This is a "AETNA" identifier , issued by the state of ( OH ) . This identifiers is of the category "OTHER".
• Identifier: 000000558054 . This is a "ANTHEM" identifier , issued by the state of ( OH ) . This identifiers is of the category "OTHER".
• Identifier: 2146663 , issued by the state of ( OH ) . This identifiers is of the category "MEDICAID".
• Identifier: 440046 . This is a "WELLCARE" identifier , issued by the state of ( OH ) . This identifiers is of the category "OTHER".
• Identifier: 753959 . This is a "BUCKEYE" identifier , issued by the state of ( OH ) . This identifiers is of the category "OTHER".
• Identifier: 932856559A , issued by the state of ( GA ) . This identifiers is of the category "MEDICAID".