Basic Information
| Provider Information | |||||||||
| NPI: | 1497701023 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | COOPERSTOCK | ||||||||
| FirstName: | MICHAEL | ||||||||
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| Credential: | MD | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 843966 | ||||||||
| Address2: | |||||||||
| City: | KANSAS CITY | ||||||||
| State: | MO | ||||||||
| PostalCode: | 641843966 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5738823974 | ||||||||
| FaxNumber: | 5738840943 | ||||||||
| Practice Location | |||||||||
| Address1: | 404 N KEENE ST | ||||||||
| Address2: | |||||||||
| City: | COLUMBIA | ||||||||
| State: | MO | ||||||||
| PostalCode: | 652016626 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5738826921 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 05/25/2006 | ||||||||
| LastUpdateDate: | 03/17/2018 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 2080P0208X | R5666 | MO | Y | Allopathic & Osteopathic Physicians | Pediatrics | Pediatric Infectious Diseases | 208000000X | R5666 | MO | N | Allopathic & Osteopathic Physicians | Pediatrics |
ID Information
| ID | Type | State | Issuer | Description | 11588 | 01 | MO | BLUE SHIELD | OTHER | 9209005 | 01 | MO | UNITED HEALTHCARE | OTHER | 11588 | 01 | MO | BLUE CHOICE | OTHER | 102434 | 01 | MO | HEALTHLINK | OTHER | 200527802 | 05 | MO | MEDICAID | 2086988101 | 01 | MO | KANSAS MEDICAID | OTHER |