Provider Demographics
NPI:1104836733
Name:COOKE, KENNETH ROBERT (MD)
Entity Type:Individual
Prefix:
First Name:KENNETH
Middle Name:ROBERT
Last Name:COOKE
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:6201 GREENLEIGH AVE
Mailing Address - Street 2:
Mailing Address - City:BALTIMORE
Mailing Address - State:MD
Mailing Address - Zip Code:21220-2004
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:CRB1 RM 207
Practice Address - Street 2:1650 ORLEANS STREET,
Practice Address - City:BALTIMORE
Practice Address - State:MD
Practice Address - Zip Code:21287-0001
Practice Address - Country:US
Practice Address - Phone:443-287-2949
Practice Address - Fax:410-502-7223
Is Sole Proprietor?:No
Enumeration Date:2006-08-08
Last Update Date:2023-04-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI4301074004208000000X, 2080P0207X
OH350909842080P0207X
MDD762042080P0207X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2080P0207XAllopathic & Osteopathic PhysiciansPediatricsPediatric Hematology-Oncology
No208000000XAllopathic & Osteopathic PhysiciansPediatrics
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH000000233275OtherUNISON
MI4173898Medicaid
OH5752459OtherAETNA
OH000000558054OtherANTHEM
OH2146663Medicaid
OH440046OtherWELLCARE
OH753959OtherBUCKEYE
GA932856559AMedicaid
OH000000558054OtherANTHEM
OH440046OtherWELLCARE
OHP00760950Medicare PIN