Healthcare Provider Details

I. General information

NPI: 1093535031
Provider Name (Legal Business Name): MRS. KEIARA COOPER
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 10/15/2024
Last Update Date: 10/15/2024
Certification Date: 10/15/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

801 N BROADWAY
BALTIMORE MD
21205-1424
US

IV. Provider business mailing address

21 TEMONS CT
WINDSOR MILL MD
21244-1465
US

V. Phone/Fax

Practice location:
  • Phone: 443-923-9468
  • Fax:
Mailing address:
  • Phone: 443-965-0329
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code2081P0004X
TaxonomySpinal Cord Injury Medicine Physician
License NumberA5969
License Number StateMD

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: