Provider Demographics
NPI: | 1003870817 |
---|---|
Name: | COHEN, CARRIE E (DO) |
Entity Type: | Individual |
Prefix: | |
First Name: | CARRIE |
Middle Name: | E |
Last Name: | COHEN |
Suffix: | |
Gender: | F |
Credentials: | DO |
Other - Prefix: | |
Other - First Name: | |
Other - Middle Name: | |
Other - Last Name: | |
Other - Suffix: | |
Other - Last Name Type: | |
Other - Credentials: | |
Mailing Address - Street 1: | 775 N EDWARDS AVE |
Mailing Address - Street 2: | |
Mailing Address - City: | WICHITA |
Mailing Address - State: | KS |
Mailing Address - Zip Code: | 67203-4937 |
Mailing Address - Country: | US |
Mailing Address - Phone: | 316-858-1111 |
Mailing Address - Fax: | 316-946-5293 |
Practice Address - Street 1: | 775 N EDWARDS AVE |
Practice Address - Street 2: | |
Practice Address - City: | WICHITA |
Practice Address - State: | KS |
Practice Address - Zip Code: | 67203-4937 |
Practice Address - Country: | US |
Practice Address - Phone: | 316-858-1111 |
Practice Address - Fax: | 316-946-5293 |
Is Sole Proprietor?: | No |
Enumeration Date: | 2006-04-17 |
Last Update Date: | 2023-06-06 |
Deactivation Date: | |
Deactivation Code: | |
Reactivation Date: |
Provider Licenses
State | License ID | Taxonomies |
---|---|---|
KS | 0530647 | 208M00000X, 207Q00000X |
Provider Taxonomies
Primary? | Code | Type | Classification | Specialization |
---|---|---|---|---|
Yes | 207Q00000X | Allopathic & Osteopathic Physicians | Family Medicine | |
No | 208M00000X | Allopathic & Osteopathic Physicians | Hospitalist |
Provider Identifiers
State | Identifier ID | ID Type | Issuer |
---|---|---|---|
KS | 200265810E | Medicaid | |
KS | 105306 | Other | BLUE CROSS BLUE SHIELD |
KS | 105306 | Medicare ID - Type Unspecified | |
KS | I10516 | Medicare UPIN |