MEDICARE: BRYAN COOPER QMHS

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	171M00000X	Case Manager/Care Coordinator
2	172A00000X	Driver	RF347418	OH

General Provider Information

NPI Number	:	1043907900
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	BRYAN COOPER QMHS

Provider Business Mailing Address
First Line	:	5040 GREENHURST DR
Second Line	:
City	:	MAPLE HEIGHTS
State	:	OH
Zip	:	44137-1124
Country	:	US
Telephone Number	:	216-702-8542
Fax Number	:

Provider Business Practice Location Address
First Line	:	5040 GREENHURST DR
Second Line	:
City	:	MAPLE HEIGHTS
State	:	OH
Zip	:	44137-1124
Country	:	US
Telephone Number	:	216-702-8542
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	04/20/2023
Last Update Date	:	06/18/2024

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