Healthcare Provider Details

I. General information

NPI: 1104836733
Provider Name (Legal Business Name): KENNETH ROBERT COOKE MD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 08/08/2006
Last Update Date: 04/04/2023
Certification Date: 04/04/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

CRB1 RM 207 1650 ORLEANS STREET,
BALTIMORE MD
21287-0001
US

IV. Provider business mailing address

6201 GREENLEIGH AVE
BALTIMORE MD
21220-2004
US

V. Phone/Fax

Practice location:
  • Phone: 443-287-2949
  • Fax: 410-502-7223
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code208000000X
TaxonomyPediatrics Physician
License Number4301074004
License Number StateMI
# 2
Primary TaxonomyN
Taxonomy Code2080P0207X
TaxonomyPediatric Hematology & Oncology Physician
License Number4301074004
License Number StateMI
# 3
Primary TaxonomyN
Taxonomy Code2080P0207X
TaxonomyPediatric Hematology & Oncology Physician
License Number35090984
License Number StateOH
# 4
Primary TaxonomyY
Taxonomy Code2080P0207X
TaxonomyPediatric Hematology & Oncology Physician
License NumberD76204
License Number StateMD

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: