Provider Demographics
NPI:1871529172
Name:COOKE, KEVIN
Entity type:Individual
Prefix:
First Name:KEVIN
Middle Name:
Last Name:COOKE
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 632015
Mailing Address - Street 2:
Mailing Address - City:BALTIMORE
Mailing Address - State:MD
Mailing Address - Zip Code:21263-2015
Mailing Address - Country:US
Mailing Address - Phone:888-834-7110
Mailing Address - Fax:
Practice Address - Street 1:5755 CEDAR LN
Practice Address - Street 2:
Practice Address - City:COLUMBIA
Practice Address - State:MD
Practice Address - Zip Code:21044-2912
Practice Address - Country:US
Practice Address - Phone:410-550-9720
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-06-25
Last Update Date:2010-06-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MDD0025770207P00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207P00000XAllopathic & Osteopathic PhysiciansEmergency Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
MD022006300Medicaid
MD209141100Medicaid
MD988L609EMedicare PIN
MDD14885Medicare UPIN
MD022006300Medicaid